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Andersen TH, Marcussen TM, Nørgaard O. Information needs for GPs on type 2 diabetes in Western countries: a systematic review. Br J Gen Pract 2024:BJGP.2023.0531. [PMID: 38429111 PMCID: PMC11388096 DOI: 10.3399/bjgp.2023.0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/26/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Most people with type 2 diabetes receive treatment in primary care by GPs who are not specialised in diabetes. Thus, it is important to uncover the most essential information needs regarding type 2 diabetes in general practice. AIM To identify information needs related to type 2 diabetes for GPs. DESIGN AND SETTING Systematic review focused on literature relating to Western countries. METHOD MEDLINE, Embase, PsycInfo and CINAHL were searched from inception to January 2024. Two researchers conducted the selection process, and citation searches were performed to identify any relevant articles missed by the database search. Quality appraisal was conducted with the Mixed Methods Appraisal Tool. Meaning units were coded individually, grouped into categories, and then studies were summarised within the context of these categories using narrative synthesis. An evidence map was created to highlight research gaps. RESULTS Thirty-nine included studies revealed eight main categories and 36 subcategories of information needs. Categories were organised into a comprehensive hierarchical model of information needs, suggesting 'Knowledge of guidelines' and 'Reasons for referral' as general information needs alongside more specific needs on 'Medication', 'Management', 'Complications', 'Diagnosis', 'Risk factors', and 'Screening for diabetes'. The evidence map provides readers with the opportunity to explore the characteristics of the included studies in detail. CONCLUSION This systematic review provides GPs, policymakers, and researchers with a hierarchical model of information and educational needs for GPs, and an evidence map showing gaps in the current literature. Information needs about clinical guidelines and reasons for referral to specialised care overlapped with needs for more specific information.
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Affiliation(s)
- Tue Helms Andersen
- Danish Diabetes Knowledge Center, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Thomas Møller Marcussen
- Danish Diabetes Knowledge Center, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Ole Nørgaard
- Danish Diabetes Knowledge Center, Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Herlev, Denmark
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Montero AR, Nassar CM, Ahmed S, Magee M. Pilot feasibility and efficacy of a strategy to sustain A1C improvement among diverse adults with type 2 diabetes completing a diabetes care management program. BMJ Open Diabetes Res Care 2024; 12:e003788. [PMID: 38471671 DOI: 10.1136/bmjdrc-2023-003788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 01/25/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Evidence-based strategies are needed to sustain improvements in outcomes following diabetes care management (DCM) programs. We examined the impact of Boot Camp-Plus (BC-Plus), an innovative sustaining strategy, on A1C among adults with type 2 diabetes completing a 3-month Diabetes Boot Camp (DBC). This health system sponsored program consisted of diabetes self-management education and support, medical nutrition therapy and antihyperglycemic medications management. RESEARCH DESIGN AND METHODS From March 2019 to July 2021, adult DBC completers with Medicare or a health system Medicaid or employee commercial plan were enrolled in BC-Plus for 9 months. DBC completers not meeting insurance eligibility or who declined to participate in BC-Plus acted as controls. During the first 3 months, BC-Plus participants received ongoing daily remote blood glucose (BG) monitoring; and during all 9 months, they received monthly check-in calls with BG review by a medical assistant who addressed needs for supplies/drugs, whether participants were checking BGs, and self-care encouragement. Escalation to a nurse practitioner occurred if the monthly BG trend was >200 mg/dL and/or several BG <80 mg/dL and/or new A1C >9.0% were identified. A1C was followed for an additional 9 months post-BC-Plus. A longitudinal mixed effects analysis was used to assess change in A1C from month 0 to month 21 of follow-up between BC-Plus participants versus controls. RESULTS A total of 838 DCM completers were identified, among whom 281 joined the BC-Plus intervention and 557 acted as controls. Mean age was 55.9 years; 58.2% were women; 66.2% were black; and 30.6% insured by Medicare. BC-Plus participants experienced significantly lower A1C compared with controls and remained below 8.0% to month 18. CONCLUSIONS Among completers of a 3-month DCM program, a low intensity 9-month sustaining strategy maintained A1C under 8.0% (HEDIS (Healthcare Effectiveness Data and Information Set) threshold for diabetes control) compared with controls for 15 months after completion of the initial DCM intervention.
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Affiliation(s)
- Alex Renato Montero
- MedStar Diabetes Institute, Washington, DC, USA
- Georgetown University School of Medicine, Washington, DC, USA
- Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Carine M Nassar
- MedStar Diabetes Institute, Washington, DC, USA
- MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Saba Ahmed
- Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Michelle Magee
- MedStar Diabetes Institute, Washington, DC, USA
- Georgetown University School of Medicine, Washington, DC, USA
- MedStar Health Research Institute, Hyattsville, Maryland, USA
- MedStar Washington Hospital Center, Washington, DC, USA
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Allam MM, Younan M, Abdelhamid M, Khan M, Elshafee M, Nada AM. A 5-structured visits multidisciplinary clinical care approach to optimize the care of patients with type 2 diabetes: a pilot study. Cardiovasc Endocrinol Metab 2023; 12:e0295. [PMID: 37859940 PMCID: PMC10584289 DOI: 10.1097/xce.0000000000000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023]
Abstract
Introduction Multidisciplinary coordinated care has been associated with improvement of diabetes care. Aim and methods This is a retrospective cohort analysis aimed to assess the effect of application of the five-structured visits Multi-disciplinary Clinical Care Approach (FMCA) on each of T2DM control, complications and comorbidities. The patients' records were assessed for one year of regular diabetes care followed with a year after implementation of FMCA for patients attending the diabetes clinic at Zulekha hospital. The patients were divided according to HbA1c (cutoff 7%) at the end of the FMCA year of follow-up into a group of controlled and another group of uncontrolled diabetes designated CDM and UCDM, respectively. Results 49% of patients were males and the mean age was 44.22 years. HbA1c levels, LDL and urinary albumin/creatinine ratio (UACR) showed a marked decrease among the patients after implementation of FMCA (P = 0.02, P = 0.04, P = 0.003, respectively). Compared with an increase in the atherosclerotic cardiovascular risk score (ASCVD) during the regular period, exposure to FMCA significantly decreased the cardiovascular risk score (0.17%, 11.41%, P = 0.001, P = 0.001, respectively). A self-management score was significantly higher in CDM patients. After a multivariate regression analysis of factors affecting DM control, we detected that baseline HbA1c, UACR, self-management score and hospital admission rate were the most important factors to predict diabetes control. Conclusion The implementation of FMCA has shown a significant improvement in clinical and humanistic aspects of individuals with T2DM with a better outcome, more control and less complications.
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Affiliation(s)
- Magdy Mohamed Allam
- Alexandria University, Alexandria, Egypt
- Zulekha Hospital, Dubai, United Arab Emirates
| | - Mariam Younan
- Cairo University teaching Hospital, Cairo, Egypt
- Zulekha Hospital
| | | | | | | | - Aml Mohamed Nada
- Diabetes and Metabolism, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Goh LH, Siah CJR, Tam WWS, Tai ES, Young DYL. Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis. Syst Rev 2022; 11:273. [PMID: 36522687 PMCID: PMC9753411 DOI: 10.1186/s13643-022-02117-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Mixed evidence exists regarding the effectiveness of the Chronic Care Model (CCM) with patient outcomes. The aim of this review is to examine the effectiveness of CCM interventions on hemoglobin A1c (HbA1c), systolic BP (SBP), diastolic BP (DBP), LDL cholesterol and body mass index (BMI) among primary care adults with type 2 diabetes. METHODS PubMed, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, Scopus and Web of Science were searched from January 1990 to June 2021 for randomized controlled trials (RCTs) comparing CCM interventions against usual care among adults with type 2 diabetes mellitus in primary care with HbA1c, SBP, DBP, LDL cholesterol and BMI as outcomes. An abbreviated search was performed from 2021 to April 2022. This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for data extraction and Cochrane risk of bias assessment. Two reviewers independently extracted the data. Meta-analysis was performed using Review Manager software. Heterogeneity was evaluated using χ2 and I2 test statistics. Overall effects were evaluated using Z statistic. RESULTS A total of 17 studies involving 16485 patients were identified. Most studies had low risks of bias. Meta-analysis of all 17 studies revealed that CCM interventions significantly decreased HbA1c levels compared to usual care, with a mean difference (MD) of -0.21%, 95% CI -0.30, -0.13; Z = 5.07, p<0.00001. Larger effects were experienced among adults with baseline HbA1c ≥8% (MD -0.36%, 95% CI -0.51, -0.21; Z = 5.05, p<0.00001) and when four or more CCM elements were present in the interventions (MD -0.25%, 95% CI -0.35, -0.15; Z = 4.85, p<0.00001). Interventions with CCM decreased SBP (MD -2.93 mmHg, 95% CI -4.46, -1.40, Z = 3.75, p=0.0002) and DBP (MD -1.35 mmHg, 95% CI -2.05, -0.65, Z = 3.79, p=0.0002) compared to usual care but there was no impact on LDL cholesterol levels or BMI. CONCLUSIONS CCM interventions, compared to usual care, improve glycaemic control among adults with type 2 diabetes in primary care, with greater reductions when the mean baseline HbA1c is ≥8% and with interventions containing four or more CCM elements. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021273959.
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Affiliation(s)
- Lay Hoon Goh
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228 Singapore
| | - Chiew Jiat Rosalind Siah
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - E Shyong Tai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Doris Yee Ling Young
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228 Singapore
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Brenner S, Oberaigner W, Stummer H. Should we care to adhere? Guideline adherence rates, glycemic control and physician perspective on adherence for type-2 diabetes. J Public Health (Oxf) 2021. [DOI: 10.1007/s10389-019-01182-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Kazemian P, Shebl FM, McCann N, Walensky RP, Wexler DJ. Evaluation of the Cascade of Diabetes Care in the United States, 2005-2016. JAMA Intern Med 2019; 179:1376-1385. [PMID: 31403657 PMCID: PMC6692836 DOI: 10.1001/jamainternmed.2019.2396] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Treatment advances in diabetes can meaningfully improve outcomes only if they effectively reach the populations at risk. OBJECTIVES To evaluate whether the cascade of US diabetes care, defined as diabetes diagnosis, linkage to care, and achievement of individual and combined treatment targets, improved from 2005 to 2016 and to investigate potential disparities in US diabetes care. DESIGN, SETTING, AND PARTICIPANTS Nationally representative, serial cross-sectional studies included in the 2005-2016 National Health and Nutrition Examination Survey were evaluated. Data on nonpregnant US adults (age ≥18 years) with diabetes who had reported fasting for 9 or more hours (n = 1742 diagnosed and 746 undiagnosed) were included. Data analysis was performed from August 1, 2018, to May 10, 2019. EXPOSURES Time period (2005-2008, 2009-2012, and 2013-2016), age, sex, race/ethnicity, health insurance, and educational level incorporated into logistic regression models predicting odds of target achievement. MAIN OUTCOMES AND MEASURES Proportion of participants overall and stratified by age, sex, and race/ethnicity who were linked to diabetes care and met glycemic (hemoglobin A1c <7.0%-8.5%, depending on age and complications), blood pressure (<140/90 mm Hg), cholesterol level (low-density lipoprotein cholesterol <100 mg/dL), and smoking abstinence targets and a composite of all targets. RESULTS In 2013-2016, of 1742 US adults with diagnosed diabetes, 94% (95% CI, 92%-96%) were linked to diabetes care; 64% (95% CI, 58%-69%) met hemoglobin A1c level, 70% (95% CI, 64%-75%) met blood pressure level, and 57% (95% CI, 51%-62%) met cholesterol level targets; 85% were nonsmokers (95% CI, 82%-88%); and 23% (95% CI, 17%-29%) achieved the composite goal. Results were similar in 2005-2008 (composite 23%) and in 2009-2012 (composite 25%). There was no significant improvement in diagnosis or target achievement during the study period. Compared with middle-aged adults (45-64 years) with diagnosed diabetes, older patients (≥65 years) had higher odds (adjusted odds ratio [aOR], 1.70; 95% CI, 1.17-2.48) and younger adults (18-44 years) had lower odds (aOR, 0.53; 95% CI, 0.29-0.97) of meeting the composite target. Women had lower odds of achieving the composite target than men (aOR, 0.60; 95% CI, 0.45-0.80). Non-Hispanic black individuals vs non-Hispanic white individuals had lower odds of achieving the composite target (aOR, 0.57; 95% CI, 0.39-0.83). Having health insurance was the strongest predictor of linkage to diabetes care (aOR, 3.96; 95% CI, 2.34-6.69). CONCLUSIONS AND RELEVANCE It appears that the diabetes care cascade in the United States has not significantly improved between 2005 and 2016. This study's findings suggest that gaps in diabetes care that were present in 2005, particularly among younger adults (18-44 years), women, and nonwhite individuals, persist.
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Affiliation(s)
- Pooyan Kazemian
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts
| | - Fatma M Shebl
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Nicole McCann
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston
| | - Rochelle P Walensky
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston.,Division of General Internal Medicine, Massachusetts General Hospital, Boston.,Harvard Medical School, Boston, Massachusetts.,Division of Infectious Diseases, Massachusetts General Hospital, Boston
| | - Deborah J Wexler
- Harvard Medical School, Boston, Massachusetts.,Diabetes Unit, Massachusetts General Hospital, Boston
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Ose D, Kamradt M, Kiel M, Freund T, Besier W, Mayer M, Krisam J, Wensing M, Salize HJ, Szecsenyi J. Care management intervention to strengthen self-care of multimorbid patients with type 2 diabetes in a German primary care network: A randomized controlled trial. PLoS One 2019; 14:e0214056. [PMID: 31188825 PMCID: PMC6561631 DOI: 10.1371/journal.pone.0214056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 02/22/2019] [Indexed: 02/06/2023] Open
Abstract
Purpose This study aimed to assess the effectiveness of a care management intervention in improving self-management behavior in multimorbid patients with type 2 diabetes; care was delivered by medical assistants in the context of a primary care network (PCN) in Germany. Methods This study is an 18-month, multi-center, two-armed, open-label, patient-randomized parallel-group superiority trial (ISRCTN 83908315). The intervention group received the care management intervention in addition to the usual care. The control group received usual care only. The primary outcome was the change in self-care behavior at month 9 compared to baseline. The self-care behavior was measured with the German version of the Summary of Diabetes Self-Care Activities Measure (SDSCA-G). A multilevel regression analysis was applied. Results We assigned 495 patients to intervention (n = 252) and control (n = 243). At baseline, the mean age was 68 ±11 years, 47.8% of the patients were female and the mean HbA1c was 7.1±1.2%. The primary analysis showed no statistically significant effect, but a positive trend was observed (p = 0.206; 95%-CI = -0.084; 0.384). The descriptive analysis revealed a significantly increased sum score of the SDSCA-G in the intervention group over time (P = 0.012) but not in the control group (p = 0.1973). Conclusion The sum score for self-care behavior markedly improved in the intervention group over time. However, the results of our primary analysis showed no statistically significant effect. Possible reasons are the high baseline performance in our sample and the low intervention fidelity. The implementation of this care management intervention in PCNs has the potential to improve self-care behavior of multimorbid patients with type 2 diabetes.
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Affiliation(s)
- Dominik Ose
- University of Utah, Department of Family and Preventive Medicine, Salt Lake City, UT, United States of America
- University Hospital Heidelberg; Department of General Practice and Health Services Research; Marsilius-Arkaden, Turm West, Heidelberg, Germany
- * E-mail:
| | - Martina Kamradt
- University Hospital Heidelberg; Department of General Practice and Health Services Research; Marsilius-Arkaden, Turm West, Heidelberg, Germany
| | - Marion Kiel
- University Hospital Heidelberg; Department of General Practice and Health Services Research; Marsilius-Arkaden, Turm West, Heidelberg, Germany
| | - Tobias Freund
- University Hospital Heidelberg; Department of General Practice and Health Services Research; Marsilius-Arkaden, Turm West, Heidelberg, Germany
| | - Werner Besier
- Genossenschaft Gesundheitsprojekt Mannheim e.G., Mannheim, Germany
| | - Manfred Mayer
- Genossenschaft Gesundheitsprojekt Mannheim e.G., Mannheim, Germany
| | - Johannes Krisam
- University Hospital Heidelberg, Institute of Medical Biometry and Informatics, Marsilius-Arkaden, Turm West, Heidelberg, Germany
| | - Michel Wensing
- University Hospital Heidelberg; Department of General Practice and Health Services Research; Marsilius-Arkaden, Turm West, Heidelberg, Germany
| | - Hans-Joachim Salize
- Central Institute of Mental Health, Medical Faculty Mannheim / Heidelberg University, Mannheim, Germany
| | - Joachim Szecsenyi
- University Hospital Heidelberg; Department of General Practice and Health Services Research; Marsilius-Arkaden, Turm West, Heidelberg, Germany
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Olsen KR, Laudicella M. Health care inequality in free access health systems: The impact of non-pecuniary incentives on diabetic patients in Danish general practices. Soc Sci Med 2019; 230:174-183. [DOI: 10.1016/j.socscimed.2019.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/09/2018] [Accepted: 03/05/2019] [Indexed: 12/11/2022]
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Ehrenthal JC, Düx A, Baie L, Burgmer M. Levels of personality functioning and not depression predict decline of plasma glucose concentration in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2019; 151:106-113. [PMID: 30959148 DOI: 10.1016/j.diabres.2019.04.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/27/2018] [Accepted: 04/01/2019] [Indexed: 11/22/2022]
Abstract
AIMS Psychosocial variables influence chronic diseases, such as type 2 diabetes mellitus. While there is evidence for a negative impact of depression, much less is known about stable, personality oriented factors. Aim of the study was to assess the impact of depression and personality functioning on glucose regulation in patients with type 2 diabetes. METHODS Seventy-five adult individuals with a first diagnosis of type 2 diabetes were consecutively recruited in an outpatient medical practice. Plasma glucose (HbA1c) was measured at initial contact, and after three and six months of a standardized disease management program. Depression was assessed by self-report (Patient Health Questionnaire, PHQ-D), levels of personality functioning with the screening version of the Operationalized Psychodynamic Diagnosis structure questionnaire (OPD-SQS). RESULTS Using mixed regression models, OPD-SQS scores were associated with lower baseline levels of HbA1c, but a less steep decline over time. PHQ-D scores were neither associated with intercept nor with slopes of HbA1c. CONCLUSIONS In type 2 diabetes, levels of personality functioning but not depression predicted decline in plasma glucose during the first six months of a standardized disease management program. Personality functioning may be especially important in chronic diseases that demand a high level of compliance and lifestyle change.
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Affiliation(s)
| | - Andreas Düx
- Department of Psychosomatics and Psychotherapy, University Hospital Münster, Münster, Germany.
| | - Lara Baie
- Department of Psychosomatics and Psychotherapy, University Hospital Münster, Münster, Germany.
| | - Markus Burgmer
- Department of Psychosomatics and Psychotherapy, University Hospital Münster, Münster, Germany.
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Magee MF, Baker KM, Fernandez SJ, Huang CC, Mete M, Montero AR, Nassar CM, Sack PA, Smith K, Youssef GA, Evans SR. Redesigning ambulatory care management for uncontrolled type 2 diabetes: a prospective cohort study of the impact of a Boot Camp model on outcomes. BMJ Open Diabetes Res Care 2019; 7:e000731. [PMID: 31798894 PMCID: PMC6861097 DOI: 10.1136/bmjdrc-2019-000731] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/23/2019] [Accepted: 09/30/2019] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVE Type 2 diabetes care management (DCM) is challenging. Few studies report meaningful improvements in clinical care settings, warranting DCM redesign. We developed a Boot Camp to provide timely, patient-centered, technology-enabled DCM. Impact on hemoglobin A1c (HbA1c), emergency department (ED) visits and hospitalizations among adults with uncontrolled type 2 diabetes were examined. RESEARCH DESIGN AND METHODS The intervention was designed using the Practical Robust Implementation and Sustainability Model to embed elements of the chronic care model. Adults with HbA1c>9% (75 mmol/mol) enrolled between November 2014 and November 2017 received diabetes education and medication management by diabetes educators and nurse practitioners via initial clinic and subsequent weekly virtual visits, facilitated by near-real-time blood glucose transmission for 90 days. HbA1c and risk for ED visits and hospitalizations at 90 days, and potential savings from reducing avoidable medical utilizations were examined. Boot Camp completers were compared with concurrent, propensity-matched chart controls receiving usual DCM in primary care practices. RESULTS A cohort of 366 Boot Camp participants plus 366 controls was analyzed. Participants were 79% African-American, 63% female and 59% Medicare-insured or Medicaid-insured and mean age 56 years. Baseline mean HbA1c for cases and controls was 11.2% (99 mmol/mol) and 11.3% (100 mmol/mol), respectively. At 90 days, HbA1c was 8.1% (65 mmol/mol) and 9.9% (85 mmol/mol), p<0.001, respectively. Risk for 90-day all-cause hospitalizations decreased 77% for participants and increased 58% for controls, p=0.036. Mean potential for monetization of US$3086 annually per participant for averted hospitalizations were calculated. CONCLUSIONS Redesigning diabetes care management using a pragmatic technology-enabled approach supported translation of evidence-based best practices across a mixed-payer regional healthcare system. Diabetes educators successfully participated in medication initiation and titration. Improvement in glycemic control, reduction in hospitalizations and potential for monetization was demonstrated in a high-risk cohort of adults with uncontrolled type 2 diabetes. TRIAL REGISTRATION NUMBER NCT02925312.
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Affiliation(s)
- Michelle F Magee
- MedStar Health Research Institute, Hyattsville, Maryland, USA
- Department of Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
- MedStar Diabetes Institute, MedStar Health, Columbia, Maryland, USA
| | - Kelley M Baker
- MedStar Institute for Quality and Safety, Columbia, Maryland, USA
| | - Stephen J Fernandez
- Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Chun-Chi Huang
- Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Mihriye Mete
- Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Alex R Montero
- Department of Medicine, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
- MedStar Diabetes Institute, MedStar Health, Columbia, Maryland, USA
| | - Carine M Nassar
- MedStar Health Research Institute, Hyattsville, Maryland, USA
- MedStar Diabetes Institute, MedStar Health, Columbia, Maryland, USA
| | - Paul A Sack
- Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
- School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Kelly Smith
- MedStar Institute for Quality and Safety, Columbia, Maryland, USA
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Karl FM, Holle R, Schwettmann L, Peters A, Laxy M. Time preference, outcome expectancy, and self-management in patients with type 2 diabetes. Patient Prefer Adherence 2018; 12:1937-1945. [PMID: 30288034 PMCID: PMC6163016 DOI: 10.2147/ppa.s175045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Patient self-management is crucial to prevent complications and mortality in type 2 diabetes. From an economic perspective, time preference predicts short-sighted decision making and thus might help to explain non-adherence to self-anagement recommendations. However, recent studies on this association have shown mixed results. PURPOSE In this study, we tested whether the combination of time preference and outcome expectancy can improve the predictions of self-management behavior. PATIENTS AND METHODS Data from 665 patients with type 2 diabetes were obtained from the cross-sectional KORA (Cooperative Health Research in the Region of Augsburg) GEFU 4 study. Time preference and outcome expectancy were measured by one question each, which were answered on a 4-point Likert scale. Their association with six self-managing behaviors was tested in logistic and linear regression analyses. Likewise, we examined the association between self-management and the interaction of outcome expectancy and time preference. RESULTS A high time preference was associated with a significantly lower sum of self-management behaviors (β=-0.29, 95% CI [-0.54, -0.04]). Higher outcome expectancy was associated with a higher self-management score (β=0.21, 95% CI [-0.03, 0.45]). The interaction model showed that low time preference was only associated with better self-management when combined with a high outcome expectancy (β=0.05, 95% CI [-0.28, 0.39] vs β=0.27, 95% CI [-0.09, 0.63]). CONCLUSION Time preference and outcome expectancy are interrelated predictors of patient self-management and could be used to identify and to intervene on patients with a potentially poor self-management.
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Affiliation(s)
- Florian M Karl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Neuherberg, Germany,
- German Center for Diabetes Research (DZD), Neuherberg, Germany,
| | - Rolf Holle
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Neuherberg, Germany,
- German Center for Diabetes Research (DZD), Neuherberg, Germany,
| | - Lars Schwettmann
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Neuherberg, Germany,
| | - Annette Peters
- German Center for Diabetes Research (DZD), Neuherberg, Germany,
- Institute of Epidemiology II, Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Neuherberg, Germany
| | - Michael Laxy
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH), German Research Center for Environmental Health, Neuherberg, Germany,
- German Center for Diabetes Research (DZD), Neuherberg, Germany,
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Holtrop JS, Ruland S, Diaz S, Morrato EH, Jones E. Using Social Network Analysis to Examine the Effect of Care Management Structure on Chronic Disease Management Communication Within Primary Care. J Gen Intern Med 2018; 33:612-620. [PMID: 29313225 PMCID: PMC5910335 DOI: 10.1007/s11606-017-4247-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 07/19/2017] [Accepted: 11/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Care management and care managers are becoming increasingly prevalent in primary care medical practice as a means of improving population health and reducing unnecessary care. Care managers are often involved in chronic disease management and associated transitional care. In this study, we examined the communication regarding chronic disease care within 24 primary care practices in Michigan and Colorado. We sought to answer the following questions: Do care managers play a key role in chronic disease management in the practice? Does the prominence of the care manager's connectivity within the practice's communication network vary by the type of care management structure implemented? METHODS Individual written surveys were given to all practice members in the participating practices. Survey questions assessed demographics as well as practice culture, quality improvement, care management activities, and communication regarding chronic disease care. Using social network analysis and other statistical methods, we analyzed the communication dynamics related to chronic disease care for each practice. RESULTS The structure of chronic disease communication varies greatly from practice to practice. Care managers who were embedded in the practice or co-located were more likely to be in the core of the communication network than were off-site care managers. These care managers also had higher in-degree centrality, indicating that they acted as a hub for communication with team members in many other roles. DISCUSSION Social network analysis provided a useful means of examining chronic disease communication in practice, and highlighted the central role of care managers in this communication when their role structure supported such communication. Structuring care managers as embedded team members within the practice has important implications for their role in chronic disease communication within primary care.
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Affiliation(s)
- Jodi Summers Holtrop
- Department of Family Medicine, School of Medicine , University of Colorado Denver, Aurora, CO, USA.
| | - Sandra Ruland
- Department of Family Medicine, School of Medicine , University of Colorado Denver, Aurora, CO, USA
| | - Stephanie Diaz
- Department of Family Medicine, School of Medicine , University of Colorado Denver, Aurora, CO, USA
| | - Elaine H Morrato
- Department of Health Systems, Management and Policy, Colorado School of Public Health, University of Colorado Denver, Aurora, CO, USA
| | - Eric Jones
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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Bongaerts BWC, Müssig K, Wens J, Lang C, Schwarz P, Roden M, Rathmann W. Effectiveness of chronic care models for the management of type 2 diabetes mellitus in Europe: a systematic review and meta-analysis. BMJ Open 2017; 7:e013076. [PMID: 28320788 PMCID: PMC5372084 DOI: 10.1136/bmjopen-2016-013076] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES We evaluated the effectiveness of European chronic care programmes for type 2 diabetes mellitus (characterised by integrative care and a multicomponent framework for enhancing healthcare delivery), compared with usual diabetes care. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE, Embase, CENTRAL and CINAHL from January 2000 to July 2015. ELIGIBILITY CRITERIA Randomised controlled trials focussing on (1) adults with type 2 diabetes, (2) multifaceted diabetes care interventions specifically designed for type 2 diabetes and delivered in primary or secondary care, targeting patient, physician and healthcare organisation and (3) usual diabetes care as the control intervention. DATA EXTRACTION Study characteristics, characteristics of the intervention, data on baseline demographics and changes in patient outcomes. DATA ANALYSIS Weighted mean differences in change in HbA1c and total cholesterol levels between intervention and control patients (95% CI) were estimated using a random-effects model. RESULTS Eight cluster randomised controlled trials were identified for inclusion (9529 patients). One year of multifaceted care improved HbA1c levels in patients with screen-detected and newly diagnosed diabetes, but not in patients with prevalent diabetes, compared to usual diabetes care. Across all seven included trials, the weighted mean difference in HbA1c change was -0.07% (95% CI -0.10 to -0.04) (-0.8 mmol/mol (95% CI -1.1 to -0.4)); I2=21%. The findings for total cholesterol, LDL-cholesterol and blood pressure were similar to HbA1c, albeit statistical heterogeneity between studies was considerably larger. Compared to usual care, multifaceted care did not significantly change quality of life of the diabetes patient. Finally, measured for screen-detected diabetes only, the risk of macrovascular and mircovascular complications at follow-up was not significantly different between intervention and control patients. CONCLUSIONS Effects of European multifaceted diabetes care patient outcomes are only small. Improvements are somewhat larger for screen-detected and newly diagnosed diabetes patients than for patients with prevalent diabetes.
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Affiliation(s)
- Brenda W C Bongaerts
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, Düsseldorf, Germany
| | - Karsten Müssig
- German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Johan Wens
- Department of Medicine and Health Sciences, Primary and Interdisciplinary Care Antwerp, University of Antwerp, Antwerp, Belgium
| | - Caroline Lang
- Department of Medicine III, Division of Prevention and Care of Diabetes, University of Dresden, Dresden, Germany
| | - Peter Schwarz
- Department of Medicine III, Division of Prevention and Care of Diabetes, University of Dresden, Dresden, Germany
| | - Michael Roden
- German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology and Diabetology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD e.V.), Partner Düsseldorf, Düsseldorf, Germany
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14
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Harrison SL. Clinician's Commentary on Figueiredo et al. 1. Physiother Can 2017; 69:81-82. [PMID: 28191838 DOI: 10.3138/ptc.2015-68-cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Samantha L Harrison
- Senior Lecturer, Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough, United Kingdom;
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15
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Kostev K, Rockel T, Jacob L. Impact of Disease Management Programs on HbA1c Values in Type 2 Diabetes Patients in Germany. J Diabetes Sci Technol 2017; 11:117-122. [PMID: 27246670 PMCID: PMC5375061 DOI: 10.1177/1932296816651633] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim was to analyze the impact of disease management programs on HbA1c values in type 2 diabetes mellitus (T2DM) patients in Germany. METHODS This study included 9017 patients followed in disease management programs (DMPs) who started an antihyperglycemic treatment upon inclusion in a DMP. Standard care (SC) patients were included after individual matching (1:1) to DMP cases based on age, gender, physician (diabetologist versus nondiabetologist care), HbA1c values at baseline, and index year. The main outcome was the share of patients with HbA1c <7.5% or 6.5% after at least 6 months and less than 12 months of therapy in DMP and SC groups. Multivariate logistic regression models were fitted with HbA1c level as a dependent variable and the potential predictor (DMP versus SC). RESULTS The mean age was 64.3 years and 54.7% of the patients were men. The mean HbA1c level at baseline was equal to 8.7%. In diabetologist practices, 64.7% of DMP patients and 55.1% of SC patients had HbA1c levels <7.5%, while 23.4% of DMP patients and 16.9% of SC patients had HbA1c levels <6.5% ( P values < .001). By comparison, in general practices, 72.4% of DMP patients and 65.7% of SC patients had HbA1c levels <7.5%, while 29.0% of DMP patients and 25.4% of SC patients had HbA1c levels <6.5% ( P values < .001). DMPs increased the likelihood of HbA1c levels lower than 7.5% or 6.5% after 6 months of therapy in both diabetologist and general care practices. CONCLUSION The present study indicates that the enrollment of T2DM patients in DMPs has a positive impact on HbA1c values in Germany.
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Affiliation(s)
- Karel Kostev
- IMS Health, Frankfurt, Germany
- Karel Kostev, DMSc, PhD, IMS Health, Epidemiology, Darmstädter Landstraße 1089, 60598 Frankfurt am Main, Germany.
| | | | - Louis Jacob
- Department of Biology, École Normale Supérieure de Lyon, Lyon, France
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Murad MH, Almasri J, Alsawas M, Farah W. Grading the quality of evidence in complex interventions: a guide for evidence-based practitioners. ACTA ACUST UNITED AC 2016; 22:20-22. [PMID: 27932400 DOI: 10.1136/ebmed-2016-110577] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Evidence-based practitioners who want to apply evidence from complex interventions to the care of their patients are often challenged by the difficulty of grading the quality of this evidence. Using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach and an illustrative example, we propose a framework for evaluating the quality of evidence that depends on obtaining feedback from the evidence user (eg, guideline panel) to inform: (1) proper framing of the question, (2) judgements about directness and consistency of evidence and (3) the need for additional contextual and qualitative evidence. Using this framework, different evidence users and based on their needs would consider the same evidence as high, moderate, low or very low.
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Affiliation(s)
- M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Jehad Almasri
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouaz Alsawas
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Wigdan Farah
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
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17
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Tomoaia-Cotisel A, Farrell TW, Solberg LI, Berry CA, Calman NS, Cronholm PF, Donahue KE, Driscoll DL, Hauser D, McAllister JW, Mehta SN, Reid RJ, Tai-Seale M, Wise CG, Fetters MD, Holtrop JS, Rodriguez HP, Brunker CP, McGinley EL, Day RL, Scammon DL, Harrison MI, Genevro JL, Gabbay RA, Magill MK. Implementation of Care Management: An Analysis of Recent AHRQ Research. Med Care Res Rev 2016; 75:46-65. [PMID: 27789628 DOI: 10.1177/1077558716673459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.
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Affiliation(s)
- Andrada Tomoaia-Cotisel
- 1 The RAND Corporation, Boston, MA, USA.,2 University of Utah, Salt Lake City, UT, USA.,3 London School of Hygiene and Tropical Medicine, London, UK
| | - Timothy W Farrell
- 2 University of Utah, Salt Lake City, UT, USA.,4 VA Geriatric Research, Education, and Clinical Center, Salt Lake City, UT, USA
| | - Leif I Solberg
- 5 HealthPartners Institute for Education and Research, Minneapolis, MN, USA
| | | | | | | | | | | | - Diane Hauser
- 7 Institute for Family Health, New York, NY, USA
| | | | - Sanjeev N Mehta
- 12 Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Robert J Reid
- 13 Group Health Research Institute, Seattle, WA, USA
| | - Ming Tai-Seale
- 14 Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA
| | | | | | | | | | | | | | | | | | | | - Janice L Genevro
- 20 Agency for Healthcare Research and Quality, Rockville, MD, USA
| | - Robert A Gabbay
- 12 Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
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18
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Casanova L, Bocquier A, Cortaredona S, Nauleau S, Sauze L, Sciortino V, Villani P, Verger P. Membership in a diabetes-care network and adherence to clinical practice guidelines for treating type 2 diabetes among general practitioners: A four-year follow-up. Prim Care Diabetes 2016; 10:342-351. [PMID: 27483997 DOI: 10.1016/j.pcd.2016.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/03/2016] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess whether private general practitioners (GPs) belonging to a diabetes-care network adhered more closely to clinical practice guidelines for diabetes care than GPs not in such a network, for all their patients with type 2 diabetes treated with medication (patients with diabetes), regardless of whether they received care through a network (that is, whether a halo effect occurred). RESEARCH DESIGN AND MEASURES The study, based on health insurance reimbursement databases in southeastern France, included 468 GPs in two networks and 468 non-network GPs in the same geographical area, matched one-to-one by propensity scores. We followed up their patients with diabetes (n=22,808) from 2008 through 2011, conducting multivariate time-to-event analyses (Cox models) that took the matching design into account to evaluate time from inclusion until performance of the given number of each of six recommended examinations/tests. RESULTS GPs belonging to a diabetes-care network adhered more closely to clinical practice guidelines but our result were slightly pronounced. Hazard ratios (HR) were significantly higher for patients of network GPs for the implementation of 3 HbA1C assays (HRa=1.13; [95%CI=1.10-1.16]), or 1 microalbuminuria assay (1.4 [1.35-1.45]); they were lower for LDL-cholesterol assays (1.04 [1.01-1.07]) and ophthalmological checkups (1.07 [1.04-1.10]), and not significant for creatinemia or cardiac monitoring. CONCLUSIONS Network GPs had better diabetes monitoring practices for all their patients with diabetes than the other GPs, especially for the most diabetes-specific tests. Further research is needed in other settings to confirm the existence of this halo effect.
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Affiliation(s)
- Ludovic Casanova
- ORS PACA, Southeastern Health Regional Observatory, Marseille, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information, Marseille, France; Aix Marseille University, Department of General Practice, Marseille, France.
| | - Aurélie Bocquier
- ORS PACA, Southeastern Health Regional Observatory, Marseille, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information, Marseille, France; Aix Marseille University, Department of General Practice, Marseille, France
| | - Sébastien Cortaredona
- ORS PACA, Southeastern Health Regional Observatory, Marseille, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information, Marseille, France; Aix Marseille University, Department of General Practice, Marseille, France
| | - Stève Nauleau
- Agence régionale de santé PACA (Regional Health Agency), Department of Studies and Observation, Marseille, France
| | - Laurent Sauze
- Agence régionale de santé PACA (Regional Health Agency), Department of Studies and Observation, Marseille, France
| | - Vincent Sciortino
- Direction Régionale du Service Médical de l'Assurance Maladie Provence-Alpes-Côte d'Azur et Corse (CNAMTS), France
| | - Patrick Villani
- Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information, Marseille, France
| | - Pierre Verger
- ORS PACA, Southeastern Health Regional Observatory, Marseille, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, Economics and Social Sciences Applied to Health & Analysis of Medical Information, Marseille, France; Aix Marseille University, Department of General Practice, Marseille, France
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A comparison of care management delivery models on the trajectories of medical costs among patients with chronic diseases: 4-year follow-up results. HEALTH SERVICES AND OUTCOMES RESEARCH METHODOLOGY 2016. [DOI: 10.1007/s10742-016-0160-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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20
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Simon-Tuval T, Shmueli A, Harman-Boehm I. Adherence to Self-Care Behaviors among Patients with Type 2 Diabetes-The Role of Risk Preferences. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2016; 19:844-851. [PMID: 27712713 DOI: 10.1016/j.jval.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 03/29/2016] [Accepted: 04/03/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To examine whether the degree of risk aversion is associated with adherence to disease self-management among adults with type 2 diabetes. METHODS This was a cross-sectional study of patients with type 2 diabetes (n = 408) aged 21 to 70 years who presented for routine visits in the diabetes clinic at a university medical center in Beer-Sheva, Israel. The authors used validated questionnaires to estimate adherence, risk preferences, motivation, self-efficacy, impulsivity, perceptions about the disease and the interpersonal process of care, and demographic and socioeconomic characteristics, in addition to retrieving data from computerized patient medical records of clinical indicators of disease severity. Multivariable linear and ordered-logit models examined predictors of adherence to each self-care behavior. RESULTS Multivariable analyses revealed that, compared with others, risk-seeking patients reported lower general adherence (β = -0.32; P ≤ 0.05), and specifically, lower adherence to healthful eating plan (β = -0.48; P ≤ 0.1), consumption of low-fat food (β = -0.47; P ≤ 0.1), exercise (β = -0.73; P ≤ 0.05), blood glucose monitoring (β = -0.69; P ≤ 0.05), and foot care (β = -0.36; P ≤ 0.1). Risk-seeking patients did not report lower consumption of fruits and vegetables (β = -0.19; P > 0.1). Because 96% of the study population reported optimal adherence to medication, determinants of this behavior could not be analyzed. CONCLUSIONS Risk preference is associated with adherence to self-care behaviors. Identifying risk seekers may enable practitioners to target these patients with tailored strategies to improve adherence, thus more efficiently allocating scarce health care resources.
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Affiliation(s)
- Tzahit Simon-Tuval
- Department of Health Systems Management, Guilford Glazer Faculty of Business and Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Amir Shmueli
- The Braun Hebrew University-Hadassah School of Public Health, Jerusalem, Israel
| | - Ilana Harman-Boehm
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel; Diabetes Clinic, Department of Internal Medicine C, Soroka University Medical Center, Beer-Sheva, Israel
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Holtrop JS, Potworowski G, Fitzpatrick L, Kowalk A, Green LA. Effect of care management program structure on implementation: a normalization process theory analysis. BMC Health Serv Res 2016; 16:386. [PMID: 27527614 PMCID: PMC4986276 DOI: 10.1186/s12913-016-1613-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 07/30/2016] [Indexed: 01/16/2023] Open
Abstract
Background Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice. Methods Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework. Results Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively. Conclusions Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning. Electronic supplementary material The online version of this article (doi:10.1186/s12913-016-1613-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jodi Summers Holtrop
- Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Mail stop F-496, Aurora, CO, 80045, USA.
| | - Georges Potworowski
- Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, State University of New York, Albany, NY, USA
| | - Laurie Fitzpatrick
- Department of Family Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | | | - Lee A Green
- Department of Family Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Department of Family Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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Luo Z, Chen Q, Annis AM, Piatt G, Green LA, Tao M, Holtrop JS. A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes. J Gen Intern Med 2016; 31:762-70. [PMID: 26951287 PMCID: PMC4907946 DOI: 10.1007/s11606-016-3617-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/31/2015] [Accepted: 02/01/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The real world implementation of chronic care management model varies greatly. One aspect of this variation is the delivery mode. Two contrasting strategies include provider-delivered care management (PDCM) and health plan-delivered care management (HPDCM). OBJECTIVE We aimed to compare the effectiveness of PDCM vs. HPDCM on improving clinical outcomes for patients with chronic diseases. DESIGN We used a quasi-experimental two-group pre-post design using the difference-in-differences method. PATIENTS Commercially insured patients, with any of the five chronic diseases-congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or asthma, who were outreached to and engaged in either PDCM or HPDCM were included in the study. MAIN MEASURES Outreached patients were those who received an attempted or actual contact for enrollment in care management; and engaged patients were those who had one or more care management sessions/encounters with a care manager. Effectiveness measures included blood pressure, low density lipoprotein (LDL), weight loss, and hemoglobin A1c (for diabetic patients only). Primary endpoints were evaluated in the first year of follow-up. KEY RESULTS A total of 4,000 patients were clustered in 165 practices (31 in PDCM and 134 in HPDCM). The PDCM approach demonstrated a statistically significant improvement in the proportion of outreached patients whose LDL was under control: the proportion of patients with LDL < 100 mg/dL increased by 3 % for the PDCM group (95 % CI: 1 % to 6 %) and 1 % for the HPDCM group (95 % CI: -2 % to 5 %). However, the 2 % difference in these improvements was not statistically significant (95 % CI: -2 % to 6 %). The HPDCM approach showed 3 % [95 % CI: 2 % to 6 %] improvement in overall diabetes care among outreached patients and significant reduction in obesity rates compared to PDCM (4 %, 95 % CI: 0.3 % to 8 %). CONCLUSIONS Both care management delivery modes may be viable options for improving care for patients with chronic diseases. In this commercially insured population, neither PDCM nor HPDCM resulted in substantial improvement in patients' clinical indicators in the first year. Different care management strategies within the provider-delivered programs need further investigation.
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Affiliation(s)
- Zhehui Luo
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI, USA.
| | - Qiaoling Chen
- Department of Research and Evaluation, Kaiser Permanente Sourthen California, Pasadena, CA, USA
| | - Ann M Annis
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Gretchen Piatt
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Lee A Green
- Department of Family Medicine, University of Alberta, Edmonton, AB, Canada
| | - Min Tao
- Clinical Epidemiology and Biostatistics, Blue Cross Blue Shield of Michigan, Detroit, MI, USA
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Laxy M, Stark R, Meisinger C, Kirchberger I, Heier M, von Scheidt W, Holle R. The effectiveness of German disease management programs (DMPs) in patients with type 2 diabetes mellitus and coronary heart disease: results from an observational longitudinal study. Diabetol Metab Syndr 2015; 7:77. [PMID: 26388948 PMCID: PMC4574141 DOI: 10.1186/s13098-015-0065-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/11/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the population-based German disease management programs (DMPs) for diabetes mellitus (DM) and coronary heart disease (CHD) are among the biggest worldwide, evidence on the effectiveness of these programs is still inconclusive or missing, particularly for high risk patients with comorbidities. The objective of this study was therefore to analyze the impact of DMPs on process and outcome parameters in patients with both, type 2 DM and CHD. METHODS Analyses are based on two postal surveys of patients from the KORA myocardial infarction registry (southern Germany) with type 2 DM and on two postal validation studies with patients' general physicians (2006, n = 312 and 2011, n = 212). The association between DMP enrollment (being enrolled in either DMP-DM or DMP-CHD) and guideline care (defined by several process indicators) at baseline (2006) and its development until follow-up (2011) was analyzed using logistic regression models accounting for the repeated measurements structure. The impact of DMP enrollment/guideline care on cumulated (quality-adjusted) life years ((QA)LYs) over a 4-year time horizon (2006-2010) was assessed using multiple linear regression methods. Logistic regression models were applied to analyze the association between DMP status and patient self-management at follow-up. RESULTS Being enrolled in a DMP was associated with better guideline care at baseline [OR = 2.3 (95 % CI 1.27-4.03)], but not at follow-up [OR = 0.80 (95 % CI 0.40-1.58); p value for time-interaction <0.01]. DMP enrollment was not significantly [+0.15 LYs (95 % CI -0.07, 0.37); +0.06 QALYs (95 % CI -0.15, 0.26)], but treatment according to guideline care significantly [+0.40 LYs (95 % CI 0.21-0.60); +0.28 QALYs (95 % CI 0.10-0.45)] associated with higher (quality-adjusted) survival over the 4-year follow-up period. DMP enrollees further reported a somewhat better self-management than patients not being enrolled into a DMP. CONCLUSIONS The results of this study concerning the effectiveness of DMPs in patients with DM and CHD are mixed, but are weakly in favor of DMPs. However, we found a clear positive impact of guideline care on quality adjusted survival in this patient group. The development of the association between DMP enrollment and guideline care over the follow-up time indicates some external effects, which should be the subject of further investigations.
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Affiliation(s)
- Michael Laxy
- />Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />German Center for Diabetes Research, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Renée Stark
- />Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
| | - Christa Meisinger
- />Helmholtz Zentrum München, Institute of Epidemiology II, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Inge Kirchberger
- />Helmholtz Zentrum München, Institute of Epidemiology II, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Margit Heier
- />Helmholtz Zentrum München, Institute of Epidemiology II, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />MONICA/KORA Myocardial Infarction Registry, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Wolfgang von Scheidt
- />Department of Internal Medicine I-Cardiology, Central Hospital of Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Rolf Holle
- />Helmholtz Zentrum München, Institute of Health Economics and Health Care Management, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
- />German Center for Diabetes Research, Ingolstädter Landstraße 1, 85764 Neuherberg, Germany
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Holtrop JS, Potworowski G, Fitzpatrick L, Kowalk A, Green LA. Understanding effective care management implementation in primary care: a macrocognition perspective analysis. Implement Sci 2015; 10:122. [PMID: 26292670 PMCID: PMC4545994 DOI: 10.1186/s13012-015-0316-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 08/14/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care management in primary care can be effective in helping patients with chronic disease improve their health status. Primary care practices, however, are often challenged with its implementation. Incorporating care management involves more than a simple physical process redesign to existing clinical care routines. It involves changes to who is working with patients, and consequently such things as who is making decisions, who is sharing patient information, and how. Studying the range of such changes in "knowledge work" during implementation requires a perspective and tools designed to do so. We used the macrocognition perspective, which is designed to understand how individuals think in dynamic, messy real-world environments such as care management implementation. To do so, we used cognitive task analysis to understand implementation in terms of such thinking as decision making, knowledge, and communication. METHODS Data collection involved semi-structured interviews and observations at baseline and at approximately 9 months into implementation at five practices in one physician-owned administratively connected group of practices in the state of Michigan, USA. Practices were intervention participants in a larger trial of chronic care model implementation. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with macrocognition as a guiding framework. RESULTS Seventy-four interviews and five observations were completed. There were differences in implementation success across the practices, and these differences in implementation success were well explained by macrocognition. Practices that used more macrocognition functions and used them more often were also more successful in care management implementation. CONCLUSIONS Although care management can introduce many new changes into the delivery of primary care clinical practice, implementing it successfully as a new complex intervention is possible. Macrocognition is a useful perspective for illuminating the elements that facilitate new complex interventions with a view to addressing them during implementation planning.
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Affiliation(s)
- Jodi Summers Holtrop
- Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E 17th Avenue, Mail Stop F496, Room 3505 Academic Office 1, Aurora, CO, 80045, USA.
| | - Georges Potworowski
- Department of Health Policy, Management, and Behavior, School of Public Health, University at Albany, State University of New York, Albany, NY, USA
| | - Laurie Fitzpatrick
- Department of Family Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI, USA
| | | | - Lee A Green
- Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada
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Peytremann‐Bridevaux I, Arditi C, Gex G, Bridevaux P, Burnand B. Chronic disease management programmes for adults with asthma. Cochrane Database Syst Rev 2015; 2015:CD007988. [PMID: 26014500 PMCID: PMC10640711 DOI: 10.1002/14651858.cd007988.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education. OBJECTIVES To evaluate the effectiveness of chronic disease management programmes for adults with asthma. SEARCH METHODS Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews. SELECTION CRITERIA We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months. DATA COLLECTION AND ANALYSIS After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs). MAIN RESULTS A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes. AUTHORS' CONCLUSIONS There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.
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Affiliation(s)
- Isabelle Peytremann‐Bridevaux
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineBiopôle 2Route de la Corniche 10LausanneSwitzerlandCH‐1010
| | - Chantal Arditi
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineBiopôle 2Route de la Corniche 10LausanneSwitzerlandCH‐1010
| | - Grégoire Gex
- Hôpital du ValaisService de PneumologieSionSwitzerland
| | | | - Bernard Burnand
- Lausanne University HospitalCochrane Switzerland, Institute of Social and Preventive MedicineBiopôle 2Route de la Corniche 10LausanneSwitzerlandCH‐1010
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Fuchs S, Henschke C, Blümel M, Busse R. Disease management programs for type 2 diabetes in Germany: a systematic literature review evaluating effectiveness. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:453-63. [PMID: 25019922 DOI: 10.3238/arztebl.2014.0453] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 05/07/2014] [Accepted: 05/07/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Disease management programs (DMPs) are intended to improve the care of persons with chronic diseases. Despite numerous studies there is no unequivocal evidence about the effectiveness of DMPs in Germany. METHOD We conducted a systematic literature review in the MEDLINE, EMBASE, Cochrane Library, and CCMed databases. Our analysis included all controlled studies in which patients with type 2 diabetes enrolled in a DMP were compared to type 2 diabetes patients receiving routine care with respect to process, outcome, and economic parameters. RESULTS The 9 studies included in the analysis were highly divergent with respect to their characteristics and the process and outcome parameters studied in each. No study had data beyond the year 2008. In 3 publications, the DMP patients had a lower mortality than the control patients (2.3%, 11.3%, and 7.17% versus 4.7%, 14.4%, and 14.72%). In 2 publications, DMP participation was found to be associated with a mean survival time of 1044.94 (± 189.87) days, as against 985.02 (± 264.68) in the control group. No consistent effect was seen with respect to morbidity, quality of life, or economic parameters. 7 publications from 5 studies revealed positive effects on process parameters for DMP participants. CONCLUSION The observed beneficial trends with respect to mortality and survival time, as well as improvements in process parameters, indicate that DMPs can, in fact, improve the care of patients with diabetes. Further evaluation is needed, because some changes in outcome parameters (an important indicator of the quality of care) may only be observable over a longer period of time.
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Affiliation(s)
- Sabine Fuchs
- Department of Health Care Management, Technische Universität Berlin, Shared authorship: Fuchs, Henschke and Blümel have equally contributed to the article
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Bharucha AE, Kudva Y, Basu A, Camilleri M, Low PA, Vella A, Zinsmeister AR. Relationship between glycemic control and gastric emptying in poorly controlled type 2 diabetes. Clin Gastroenterol Hepatol 2015; 13:466-476.e1. [PMID: 25041866 PMCID: PMC4297596 DOI: 10.1016/j.cgh.2014.06.034] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 03/19/2014] [Accepted: 06/28/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acute hyperglycemia delays gastric emptying in patients with diabetes. However, it is not clear whether improved control of glycemia affects gastric emptying in these patients. We investigated whether overnight and short-term (6 mo) improvements in control of glycemia affect gastric emptying. METHODS We studied 30 patients with poorly controlled type 2 diabetes (level of glycosylated hemoglobin, >9%). We measured gastric emptying using the [(13)C]-Spirulina platensis breath test on the patients' first visit (visit 1), after overnight administration of insulin or saline, 1 week later (visit 2), and 6 months after intensive therapy for diabetes. We also measured fasting and postprandial plasma levels of C-peptide, glucagon-like peptide 1, and amylin, as well as autonomic functions. RESULTS At visit 1, gastric emptying was normal in 10 patients, delayed in 14, and accelerated in 6; 6 patients had gastrointestinal symptoms; vagal dysfunction was associated with delayed gastric emptying (P < .05). Higher fasting blood levels of glucose were associated with shorter half-times of gastric emptying (thalf) at visits 1 (r = -0.46; P = .01) and 2 (r = -0.43; P = .02). Although blood levels of glucose were lower after administration of insulin (132 ± 7 mg/dL) than saline (211 ± 15 mg/dL; P = .0002), gastric emptying thalf was not lower after administration of insulin, compared with saline. After 6 months of intensive therapy, levels of glycosylated hemoglobin decreased from 10.6% ± 0.3% to 9% ± 0.4% (P = .0003), but gastric emptying thalf did not change (92 ± 8 min before, 92 ± 7 min after). Gastric emptying did not correlate with plasma levels of glucagon-like peptide 1 and amylin. CONCLUSIONS Two-thirds of patients with poorly controlled type 2 diabetes have mostly asymptomatic yet abnormal gastric emptying. Higher fasting blood levels of glucose are associated with faster gastric emptying. Overnight and sustained (6 mo) improvements in glycemic control do not affect gastric emptying.
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Affiliation(s)
- Adil E Bharucha
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota.
| | - Yogish Kudva
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Ananda Basu
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Michael Camilleri
- Clinical and Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Adrian Vella
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Takahashi PY, St Sauver JL, Finney Rutten LJ, Jacobson RM, Jacobson DJ, McGree ME, Ebbert JO. Health outcomes in diabetics measured with Minnesota Community Measurement quality metrics. Diabetes Metab Syndr Obes 2015; 8:1-8. [PMID: 25565873 PMCID: PMC4274142 DOI: 10.2147/dmso.s71726] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Our objective was to understand the relationship between optimal diabetes control, as defined by Minnesota Community Measurement (MCM), and adverse health outcomes including emergency department (ED) visits, hospitalizations, 30-day rehospitalization, intensive care unit (ICU) stay, and mortality. PATIENTS AND METHODS In 2009, we conducted a retrospective cohort study of empaneled Employee and Community Health patients with diabetes mellitus. We followed patients from 1 September 2009 until 30 June 2011 for hospitalization and until 5 January 2014 for mortality. Optimal control of diabetes mellitus was defined as achieving the following three measures: low-density lipoprotein (LDL) cholesterol <100 mg/mL, blood pressure <140/90 mmHg, and hemoglobin A1c <8%. Using the electronic medical record, we assessed hospitalizations, ED visits, ICU stays, 30-day rehospitalizations, and mortality. The chi-square or Wilcoxon rank-sum tests were used to compare those with and without optimal control. We used Cox proportional hazard models to estimate the associations between optimal diabetes mellitus status and each outcome. RESULTS We identified 5,731 empaneled patients with diabetes mellitus; 2,842 (49.6%) were in the optimal control category. After adjustment, we observed that non-optimally controlled patients had higher risks for hospitalization (hazard ratio [HR] 1.11; 95% confidence interval [CI] 1.00-1.23), ED visits (HR 1.15; 95% CI 1.06-1.25), and mortality (HR 1.29; 95% CI 1.09-1.53) than diabetic patients with optimal control. No differences were observed in ICU stay or 30-day rehospitalization. CONCLUSION Diabetic patients without optimal control had higher risks of adverse health outcomes than those with optimal control. Patients with optimal control defined by the MCM were associated with decreased morbidity and mortality.
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Affiliation(s)
- Paul Y Takahashi
- Department of Internal Medicine, Division of Primary Care Internal Medicine, Rochester, MN, USA
- Correspondence: Paul Y Takahashi, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA, Tel +1 507 284 2511, Fax +1 507 266 0036, Email
| | - Jennifer L St Sauver
- Department of Health Sciences Research, Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Lila J Finney Rutten
- Department of Health Sciences Research, Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Robert M Jacobson
- Department of Pediatric and Adolescent Medicine, Division of Community Pediatrics, Mayo Clinic, Rochester, MN, USA
| | - Debra J Jacobson
- Department of Health Sciences Research, Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Michaela E McGree
- Department of Health Sciences Research, Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Jon O Ebbert
- Department of Internal Medicine, Division of Primary Care Internal Medicine, Rochester, MN, USA
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Blakeman T, Blickem C, Kennedy A, Reeves D, Bower P, Gaffney H, Gardner C, Lee V, Jariwala P, Dawson S, Mossabir R, Brooks H, Richardson G, Spackman E, Vassilev I, Chew-Graham C, Rogers A. Effect of information and telephone-guided access to community support for people with chronic kidney disease: randomised controlled trial. PLoS One 2014; 9:e109135. [PMID: 25330169 PMCID: PMC4199782 DOI: 10.1371/journal.pone.0109135] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Implementation of self-management support in traditional primary care settings has proved difficult, encouraging the development of alternative models which actively link to community resources. Chronic kidney disease (CKD) is a common condition usually diagnosed in the presence of other co-morbidities. This trial aimed to determine the effectiveness of an intervention to provide information and telephone-guided access to community support versus usual care for patients with stage 3 CKD. METHODS AND FINDINGS In a pragmatic, two-arm, patient level randomised controlled trial 436 patients with a diagnosis of stage 3 CKD were recruited from 24 general practices in Greater Manchester. Patients were randomised to intervention (215) or usual care (221). Primary outcome measures were health related quality of life (EQ-5D health questionnaire), blood pressure control, and positive and active engagement in life (heiQ) at 6 months. At 6 months, mean health related quality of life was significantly higher for the intervention group (adjusted mean difference = 0.05; 95% CI = 0.01, 0.08) and blood pressure was controlled for a significantly greater proportion of patients in the intervention group (adjusted odds-ratio = 1.85; 95% CI = 1.25, 2.72). Patients did not differ significantly in positive and active engagement in life. The intervention group reported a reduction in costs compared with control. CONCLUSIONS An intervention to provide tailored information and telephone-guided access to community resources was associated with modest but significant improvements in health related quality of life and better maintenance of blood pressure control for patients with stage 3 CKD compared with usual care. However, further research is required to identify the mechanisms of action of the intervention. TRIAL REGISTRATION Controlled-Trials.com ISRCTN45433299.
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Affiliation(s)
- Tom Blakeman
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Anne Kennedy
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - David Reeves
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Hannah Gaffney
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Caroline Gardner
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Victoria Lee
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Praksha Jariwala
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Shoba Dawson
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Rahena Mossabir
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Helen Brooks
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Gerry Richardson
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Eldon Spackman
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Ivaylo Vassilev
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - Carolyn Chew-Graham
- Primary Care & Health Services, University of Keele, Staffordshire, United Kingdom
| | - Anne Rogers
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
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Busetto L, Luijkx KG, Vrijhoef HJM. Implementation of integrated care for type 2 diabetes: a protocol for mixed methods research. Int J Integr Care 2014; 14:e033. [PMID: 25550689 PMCID: PMC4272241 DOI: 10.5334/ijic.1516] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 10/30/2014] [Accepted: 10/30/2014] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION While integrated care for diabetes mellitus type 2 has achieved good results in terms of intermediate clinical and process outcomes, the evidence-based knowledge on its implementation is scarce, and insights generalisable to other settings therefore remain limited. OBJECTIVE This study protocol provides a description of the design and methodology of a mixed methods study on the implementation of integrated care for type 2 diabetes. The aim of the proposed research is to investigate the mechanisms by which and the context in which integrated care for type 2 diabetes has been implemented, which outcomes have been achieved and how the context and mechanisms have affected the outcomes. METHODS This article describes a convergent parallel mixed methods research design, including a systematic literature review on the implementation of integrated care for type 2 diabetes as well as a case study on two Dutch best practices on integrated care for type 2 diabetes. DISCUSSION The implementation of integrated care for diabetes type 2 is an under-researched area. Insights from this study could be applied to other settings as well as other chronic conditions to strengthen the evidence on the implementation of integrated care.
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Affiliation(s)
- Loraine Busetto
- Department of TRANZO, Faculty of Social and Behavioural Sciences, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
| | - Katrien Ger Luijkx
- Elderly Care, Department of TRANZO, Faculty of Social and Behavioural Sciences, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands
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Meader N, King K, Llewellyn A, Norman G, Brown J, Rodgers M, Moe-Byrne T, Higgins JP, Sowden A, Stewart G. A checklist designed to aid consistency and reproducibility of GRADE assessments: development and pilot validation. Syst Rev 2014; 3:82. [PMID: 25056145 PMCID: PMC4124503 DOI: 10.1186/2046-4053-3-82] [Citation(s) in RCA: 368] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 07/17/2014] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The grading of recommendation, assessment, development and evaluation (GRADE) approach is widely implemented in health technology assessment and guideline development organisations throughout the world. GRADE provides a transparent approach to reaching judgements about the quality of evidence on the effects of a health care intervention, but is complex and therefore challenging to apply in a consistent manner. METHODS We developed a checklist to guide the researcher to extract the data required to make a GRADE assessment. We applied the checklist to 29 meta-analyses of randomised controlled trials on the effectiveness of health care interventions. Two reviewers used the checklist for each paper and used these data to rate the quality of evidence for a particular outcome. RESULTS For most (70%) checklist items, there was good agreement between reviewers. The main problems were for items relating to indirectness where considerable judgement is required. CONCLUSIONS There was consistent agreement between reviewers on most items in the checklist. The use of this checklist may be an aid to improving the consistency and reproducibility of GRADE assessments, particularly for inexperienced users or in rapid reviews without the resources to conduct assessments by two researchers independently.
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Affiliation(s)
- Nick Meader
- Centre for Reviews and Dissemination, University of York, York YO10 5DD, UK.
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Chevreul K, Brunn M, Cadier B, Nolte E, Durand-Zaleski I. Evaluating structured care for diabetes: can calibration on margins help to avoid overestimation of the benefits? An illustration from French diabetes provider networks using data from the ENTRED Survey. Diabetes Care 2014; 37:1892-9. [PMID: 24784830 DOI: 10.2337/dc13-2141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE While there is growing evidence on the effectiveness of structured care for diabetic patients in trial settings, standard population level evaluations may misestimate intervention benefits due to patient selection. In order to account for potential biases in measuring intervention benefits, we tested the impact of calibration on margins as a novel adjustment method in an evaluation context compared with simple poststratification. RESEARCH DESIGN AND METHODS We compared the results of a before-after evaluation on HbA1c levels after 1 year of enrollment in a French diabetes provider network (DPN) using an unadjusted sample and samples adjusted by simple poststratification to results obtained after adjustment via calibration on margins to the general diabetic population's characteristics using a national cross-sectional sample of diabetic patients. RESULTS Both with and without adjustment, patients in the DPN had significantly lower HbA1c levels after 1 year of enrollment. However, the reductions in HbA1c levels among the adjusted samples were 22-183% lower than those measured in the unadjusted sample, regardless of the poststratification method and characteristics used. Compared with simple poststratification, estimations using calibration on margins exhibited higher performance. CONCLUSIONS Evaluations of diabetes management interventions based on uncontrolled before-after experiments may overestimate the actual benefit for patients. This can be corrected by using poststratification approaches when data on the ultimate target population for the intervention are available. In order to more accurately estimate the effect an intervention would have if extended to the target population, calibration on margins seems to be preferable over simple poststratification in terms of performance and usability.
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Affiliation(s)
- Karine Chevreul
- Université Paris Est Créteil, Université Paris Diderot, Sorbonne Paris Cité, Paris, FranceInserm, ECEVE U1123, Paris, FranceAP-HP, URC-Eco, Paris, France
| | - Matthias Brunn
- Université Paris Est Créteil, Université Paris Diderot, Sorbonne Paris Cité, Paris, FranceInserm, ECEVE U1123, Paris, FranceAP-HP, URC-Eco, Paris, France
| | - Benjamin Cadier
- Université Paris Est Créteil, Université Paris Diderot, Sorbonne Paris Cité, Paris, FranceInserm, ECEVE U1123, Paris, FranceAP-HP, URC-Eco, Paris, France
| | - Ellen Nolte
- RAND Europe, Health and Healthcare Research Programme, Cambridge, U.K
| | - Isabelle Durand-Zaleski
- Université Paris Est Créteil, Université Paris Diderot, Sorbonne Paris Cité, Paris, FranceInserm, ECEVE U1123, Paris, FranceAP-HP, URC-Eco, Paris, France
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Watts SA, Lucatorto M. A review of recent literature - nurse case managers in diabetes care: equivalent or better outcomes compared to primary care providers. Curr Diab Rep 2014; 14:504. [PMID: 24816751 DOI: 10.1007/s11892-014-0504-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Primary care has changed remarkably with chronic disease burden growth. Nurse case managers assist with this chronic disease by providing if not significantly better care, than equivalent care to that provided by usual primary care providers. Chronic disease management requires patient-centered skills and tools, such as registries, panel management, review of home data, communicating with patients outside of face-to-face care, and coordinating multiple services. Evidence reviewed in this article demonstrates that registered nurse care managers (RNCM) perform many actions required for diabetes chronic disease management including initiation and titration of medications with similar or improved physiologic and patient satisfaction outcomes over usual care providers. Selection and training of the nurse case managers is of utmost importance for implementation of a successful chronic disease management program. Evidence based guidelines, algorithms, protocols, and adequate ongoing education and mentoring are generally cited as necessary support tools for the nurse case managers.
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Affiliation(s)
- Sharon A Watts
- Office of Nursing Services, Veterans Health Administration Metabolic Syndrome and Diabetes Field Advisory Committee and Diabetes Nurse Practitioner, Louis Stokes Cleveland VA, 10701 East Blvd., W-111, Cleveland, OH, 44106, USA,
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Casanova L, Bocquier A, Cortaredona S, Nauleau S, Sauze L, Sciortino V, Villani P, Verger P. Membership in a diabetes care network improves general practitioners' practices for HbA1c and microalbuminuria monitoring: a cohort study among patients with type 2 diabetes. Diabetes Care 2014; 37:e133-4. [PMID: 24855168 DOI: 10.2337/dc13-2883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ludovic Casanova
- Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Southeastern Health Regional Observatory, Marseille, FranceINSERM, UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille, FranceDepartment of General Practice, Aix Marseille University, Marseille, France
| | - Aurélie Bocquier
- Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Southeastern Health Regional Observatory, Marseille, FranceINSERM, UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille, FranceAix Marseille University, UMR_S912, Institut de Recherche pour le Développement, Marseille, France
| | - Sébastien Cortaredona
- Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Southeastern Health Regional Observatory, Marseille, FranceINSERM, UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille, FranceAix Marseille University, UMR_S912, Institut de Recherche pour le Développement, Marseille, France
| | - Stève Nauleau
- Department of Studies and Observation, Agence Régionale de Santé Provence-Alpes-Côte d'Azur (Regional Health Agency), Marseille, France
| | - Laurent Sauze
- Department of Studies and Observation, Agence Régionale de Santé Provence-Alpes-Côte d'Azur (Regional Health Agency), Marseille, France
| | - Vincent Sciortino
- Regional Bureau of Medical Services, Provence-Alpes-Côte d'Azur-Corsica (Direction Régionale du Service Médical), National Health Insurance Fund for Salaried Workers, Marseille, France
| | - Patrick Villani
- INSERM, UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille, France
| | - Pierre Verger
- Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, Southeastern Health Regional Observatory, Marseille, FranceINSERM, UMR912 Economics and Social Sciences Applied to Health and Analysis of Medical Information, Marseille, FranceAix Marseille University, UMR_S912, Institut de Recherche pour le Développement, Marseille, France
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Henry RR, Rosenstock J, Logan D, Alessi T, Luskey K, Baron MA. Continuous subcutaneous delivery of exenatide via ITCA 650 leads to sustained glycemic control and weight loss for 48 weeks in metformin-treated subjects with type 2 diabetes. J Diabetes Complications 2014; 28:393-8. [PMID: 24631129 DOI: 10.1016/j.jdiacomp.2013.12.009] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 12/20/2013] [Accepted: 12/22/2013] [Indexed: 11/30/2022]
Abstract
AIMS Evaluate the efficacy and tolerability of ITCA 650 in subjects with type 2 diabetes treated for up to 48 weeks. METHODS This was a 24-week extension to a randomized, 24-week, open-label, phase 2 study in subjects with type 2 diabetes inadequately controlled with metformin. Subjects received ITCA 650 mg (20, 40, 60 or 80 μg/day). Mean changes for HbA1c, weight, and fasting plasma glucose (FPG) were evaluated. RESULTS Mean changes in HbA1c from baseline to week 48 ranged from -0.85% to -1.51%. At week 48, ≥64% of subjects with an HbA1c ≤7% at week 24 maintained an HbA1c ≤7%. The incidence of adverse events (AEs) was dose-related and ranged from 13.3% with 20 μg/day to 37.5% with 80 μg/day. Most AEs were mild and transient; the incidence of nausea declined from 12.9% to 9.5% over the 24-week extension. One subject on ITCA 650 80 μg/day experienced mild intermittent vomiting. Three (3.5%) subjects experienced severe AEs, but none were considered related to study drug. CONCLUSION Significant changes in HbA1c, body weight, and FPG attained with ITCA 650 were maintained to 48 weeks. The incidence of AEs was lower in the 24-week extension than in the initial 24-week treatment phase.
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Affiliation(s)
- Robert R Henry
- VA San Diego Healthcare System, San Diego, CA and University of California, San Diego, La Jolla, CA.
| | - Julio Rosenstock
- Dallas Diabetes and Endocrine Center at Medical City, Dallas, TX
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Abstract
The patient-centered medical home (PCMH) is an innovative care model for the provision of primary care that is being rapidly adopted in the U.S. with the support of federal agencies and professional organizations. Its goal is to provide comprehensive, patient-centered care with increased access, quality, and efficiency. Diabetes, as a common, costly, chronic disease that requires ongoing management by patients and providers, is a condition that is frequently monitored as a test case in PCMH implementations. While in theory a PCMH care model that supports patient engagement and between-visit care may help improve diabetes care delivery and outcomes, the success of this approach may depend largely upon the specific strategies used and implementation approach. The cost-effectiveness of diabetes care in the PCMH model is not yet clear. Interventions have been most effective and most cost-effective for those with the poorest diabetes management at baseline.
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Affiliation(s)
- Sarah A. Ackroyd
- University of Rochester School of Medicine and Dentistry Rochester, NY 14642
| | - Deborah J. Wexler
- Corresponding Author: Massachusetts General Hospital Diabetes Center and Harvard Medical School, 50 Staniford Street, Boston MA 02114, 617-726-8767 (phone); 617.726.6781 (fax),
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Crowley MJ, Bosworth HB, Coffman CJ, Lindquist JH, Neary AM, Harris AC, Datta SK, Granger BB, Pereira K, Dolor RJ, Edelman D. Tailored Case Management for Diabetes and Hypertension (TEACH-DM) in a community population: study design and baseline sample characteristics. Contemp Clin Trials 2013; 36:298-306. [PMID: 23916915 DOI: 10.1016/j.cct.2013.07.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/24/2013] [Accepted: 07/27/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite recognition of the benefits associated with well-controlled diabetes and hypertension, control remains suboptimal. Effective interventions for these conditions have been studied within academic settings, but interventions targeting both conditions have rarely been tested in community settings. We describe the design and baseline results of a trial evaluating a behavioral intervention among community patients with poorly-controlled diabetes and comorbid hypertension. METHODS Tailored Case Management for Diabetes and Hypertension (TEACH-DM) is a 24-month randomized, controlled trial evaluating a telephone-delivered behavioral intervention for diabetes and hypertension versus attention control. The study recruited from nine community practices. The nurse-administered intervention targets 3 areas: 1) cultivation of healthful behaviors for diabetes and hypertension control; 2) provision of fundamentals to support attainment of healthful behaviors; and 3) identification and correction of patient-specific barriers to adopting healthful behaviors. Hemoglobin A1c and blood pressure measured at 6, 12, and 24 months are co-primary outcomes. Secondary outcomes include self-efficacy, self-reported medication adherence, exercise, and cost-effectiveness. RESULTS Of 377 randomized patients, 193 were allocated to the intervention and 184 to attention control. The cohort is balanced in terms of gender, race, education level, and income. The cohort's mean baseline hemoglobin A1c and blood pressure are above goal, and mean baseline body mass index falls in the obese range. Baseline self-reported non-adherence is high for diabetes and hypertension medications. Trial results are pending. CONCLUSIONS If effective, the TEACH-DM intervention's telephone-based delivery strategy and nurse administration make it well-suited for rapid implementation and broad dissemination in community settings.
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Affiliation(s)
- Matthew J Crowley
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
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Kennedy A, Bower P, Reeves D, Blakeman T, Bowen R, Chew-Graham C, Eden M, Fullwood C, Gaffney H, Gardner C, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D, Rogers A. Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial. BMJ 2013; 346:f2882. [PMID: 23670660 PMCID: PMC3652644 DOI: 10.1136/bmj.f2882] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the effectiveness of an intervention to enhance self management support for patients with chronic conditions in UK primary care. DESIGN Pragmatic, two arm, cluster randomised controlled trial. SETTING General practices, serving a population in northwest England with high levels of deprivation. PARTICIPANTS 5599 patients with a diagnosis of diabetes (n=2546), chronic obstructive pulmonary disease (n=1634), and irritable bowel syndrome (n=1419) from 43 practices (19 intervention and 22 control practices). INTERVENTION Practice level training in a whole systems approach to self management support. Practices were trained to use a range of resources: a tool to assess the support needs of patients, guidebooks on self management, and a web based directory of local self management resources. Training facilitators were employed by the health management organisation. MAIN OUTCOME MEASURES Primary outcomes were shared decision making, self efficacy, and generic health related quality of life measured at 12 months. Secondary outcomes were general health, social or role limitations, energy and vitality, psychological wellbeing, self care activity, and enablement. RESULTS We randomised 44 practices and recruited 5599 patients, representing 43% of the eligible population on the practice lists. 4533 patients (81.0%) completed the six month follow-up and 4076 (72.8%) the 12 month follow-up. No statistically significant differences were found between patients attending trained practices and those attending control practices on any of the primary or secondary outcomes. All effect size estimates were well below the prespecified threshold of clinically important difference. CONCLUSIONS An intervention to enhance self management support in routine primary care did not add noticeable value to existing care for long term conditions. The active components required for effective self management support need to be better understood, both within primary care and in patients' everyday lives. TRIAL REGISTRATION Current Controlled Trials ISRCTN90940049.
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Affiliation(s)
- Anne Kennedy
- Faculty of Health Sciences, University of Southampton, Highfield Campus, Southampton SO17 1BJ, UK.
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López-López E, Gutiérrez-Soria D, Idrovo AJ. Evaluation of a diabetes care program using the effective coverage framework. Int J Qual Health Care 2012; 24:619-25. [PMID: 23042797 DOI: 10.1093/intqhc/mzs056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To measure the effective coverage of a program to control type 2 diabetes. DESIGN Observational study combining multiple DATA SOURCES SETTING Hidalgo state, Mexico. PARTICIPANTS Adults without social security health benefits and patients with a diagnosis of diabetes participating in the program. MAIN OUTCOME MEASURES Detection of diabetes; glucose, cholesterol, triglyceride and blood pressure control; education; diabetic retinopathy, diabetic foot and nephropathy prevention. RESULTS Only 7.1% of individuals with diabetes participated in the control program. Fasting glucose and HbA1c values were available for 95.6 and 35.6 of patients, respectively. There were measurements of total cholesterol (52.1%), triglyceride (50.6%) and blood pressure (99.6%). Educative activities were realized for 64.8% of patients. The most important gaps were related with detection of illness, low-density lipoprotein cholesterol control, glucose control with HbA1c and nephropathy prevention. Effective coverage of these medical actions was 6.22, 5.07, 5.01 and 0.34%, respectively. CONCLUSIONS The greatest challenge to overcome is the detection of individuals with illness because a large number of individuals with type 2 diabetes do not use health services and the health system does not systematically search them out. Medical actions that require resources that must be paid for by patients tend to be used less and to be of lower quality. The use of effective coverage to measure the performance of diabetes care program provides practical information to improve health services.
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Affiliation(s)
- Erika López-López
- Coordination of Research, Ministry of Health, Pachuca, Hidalgo, Mexico
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