The chronic care model and diabetes management in US primary care settings: a systematic review

Improving outcomes of type 2 diabetes mellitus patients in primary care with Chronic Care Model: A narrative review

Designed and implemented over two decades ago, the Chronic Care Model is a well-established chronic disease management framework that has steered several healthcare systems in successfully improving the clinical outcomes of patients with type 2 diabetes mellitus. Research evidence cements the role of the Chronic Care Model (with its six key elements of organization of healthcare delivery system, self-management support, decision support, delivery system design, clinical information systems, and community resources and policies) as an integrated framework to revamp the type 2 diabetes mellitus-related clinical practice and care that betters the patient care and clinical outcomes. The current review is an evidence-lit summary of importance of use of Chronic Care Model in primary care and their impact on clinical outcomes for patients afflicted with one of the most debilitating metabolic diseases, type 2 diabetes mellitus.

Patterns of primary and specialty care among children with sickle cell anemia

BACKGROUND AND OBJECTIVE

National guidelines recommend that children with sickle cell anemia (SCA) be seen regularly by primary care providers (PCPs) as well as hematologists to receive comprehensive, multidisciplinary care. The objective is to characterize the patterns of primary and hematology care for children with SCA in Michigan.

METHODS

Using validated claims definitions, children ages 1-17 years with SCA were identified using Michigan Medicaid administrative claims from 2010 to 2018. We calculated the number of outpatient PCP and hematologist visits per person-year, as well as the proportion of children with at least one visit to a PCP, hematologist, or both a PCP and hematologist annually. Negative binomial regression was used to calculate annual rates of visits for each provider type.

RESULTS

A total of 875 children contributed 2889 person-years. Of the total 22,570 outpatient visits, 52% were with a PCP and 34% with a hematologist. Annually, 87%-93% of children had a visit with a PCP, and 63%-85% had a visit with a hematologist. Approximately 66% of total person-years had both visit types within a year. The annual rate ranged from 2.3 to 2.5 for hematologist visits and from 3.7 to 4.1 for PCP visits.

CONCLUSIONS

Substantial gaps exist in the receipt of annual hematology care. Given that the majority of children with SCA see a PCP annually, strategies to leverage primary care visits experienced by this population may be needed to increase receipt of SCA-specific services.

Integrated patient-centred care for type 2 diabetes in Singapore Primary Care Networks: a mixed-methods study

OBJECTIVE

Patients with type 2 diabetes require patient-centred care as guided by the Chronic Care Model (CCM). Many diabetes patients in Singapore are managed by the Primary Care Networks (PCNs) which organised healthcare professionals (HCPs) comprising general practitioners, nurses and care coordinators into teams to provide diabetes care. Little is known about how the PCNs deliver care to people with type 2 diabetes. This study evaluated the consistency of diabetes care delivery in the PCNs with the CCM.

DESIGN

This was a mixed-method study. The Assessment of Chronic Illness Care (ACIC version 3.5) survey was self-administered by the HCPs in the quantitative study (ACIC scores range 0-11, the latter indicating care delivery most consistent with CCM). Descriptive statistics were obtained, and linear mixed-effects regression model was used to test for association between independent variables and ACIC total scores. The qualitative study comprised semi-structured focus group discussions and used thematic analysis.

SETTING

The study was conducted on virtual platforms involving the PCNs.

PARTICIPANTS

179 HCPs for quantitative study and 65 HCPs for qualitative study.

RESULTS

Integrated analysis of quantitative and qualitative results found that there was support for diabetes care consistent with the CCM in the PCNs. The mean ACIC total score was 5.62 (SD 1.93). The mean element scores ranged from 6.69 (SD 2.18) (Health System Organisation) to 4.91 (SD 2.37) (Community Linkages). The qualitative themes described how the PCNs provided much needed diabetes services, their characteristics such as continuity of care, patient-centred care; collaborating with community partners, financial aspects of care, enablers for and challenges in performing care, and areas for enhancement.

CONCLUSION

This mixed-methods study informs that diabetes care delivery in the Singapore PCNs is consistent with the CCM. Future research should consider using independent observers in the quantitative study and collecting objective data such as patient outcomes.

Barriers and facilitators to medical care retention for pediatric systemic lupus erythematosus in South Africa: a qualitative study

BACKGROUND

Systemic lupus erythematosus (SLE) is a life-threatening, chronic, autoimmune disease requiring long term subspecialty care due to its complex and chronic nature. Childhood-onset SLE (cSLE) is more severe than adult-onset, and the cSLE population in South Africa has been reported to have an even higher risk than patients elsewhere. Therefore, it is critical to promptly diagnose, treat, and manage cSLE. In this paper, we aim to describe and evaluate barriers and enablers of appropriate long-term care of cSLE South Africa from the perspective of caregivers (parents or family members).

METHODS

Caregivers (n = 22) were recruited through pediatric and adult rheumatology clinics. Individuals were eligible if they cared for youth (≤ 19 years) who were diagnosed with cSLE and satisfied at least four of the eleven ACR SLE classification criteria. Individual in-depth, semi-structured interviews were conducted between January 2014 and December 2014, and explored barriers to and facilitators of ongoing chronic care for cSLE. Data were analyzed using applied thematic analysis.

RESULTS

Four barriers to chronic care engagement and retention were identified: knowledge gap, financial burdens, social stigma of SLE, and complexity of the South African medical system. Additionally, we found three facilitators: patient and caregiver education, robust support system for the caregiver, and financial support for the caregiver and patient.

CONCLUSION

These findings highlight multiple, intersecting barriers to routine longitudinal care for cSLE in South Africa and suggest there might be a group of diagnosed children who don't receive follow-up care and are subject to loss to follow-up. cSLE requires ongoing treatment and care; thus, the different barriers may interact and compound over time with each follow-up visit. South African cSLE patients are at high risk for poor outcomes. South African care teams should work to overcome these barriers and place attention on the facilitators to improve care retention for these patients and create a model for other less resourced settings.

A Primer for Primary Care Physicians Managing Neurogenic Bladder Patients

Primary care plays an important role in caring for neurogenic bladder patients. Clinicians should assess neurogenic bladder patients for common urologic symptoms/signs and refer to urology if refractory or safety issues are identified.

Implementation and Outcomes of Multidisciplinary Diabetes Management Program Among Type 2 Diabetic Patients: A Comparative Study

BACKGROUND

Current guidelines recommend shifting physician-led care (PLC) for type 2 diabetes mellitus (T2DM) to more effective multidisciplinary health care (MHC). However, few researchers have studied its real-life implementation in Saudi Arabia. Therefore, we aimed to assess the implementation and compare the outcomes of an MDC diabetes management program (DMP) among T2DM patients to a PLC at a general hospital after one year of follow-up in a real-world practice setting.

METHODS

We conducted this comparative patient files review study by analyzing medical records of all T2DM patients at two private care centers. Both were compared for their effectiveness in achieving two outcomes: the glycated hemoglobin (HbA1c) <7% and low-density lipoprotein-cholesterol (LDL-c) <70 mg/dl at the end of the first year. Additionally, we assessed the implementation of the DMP.

RESULTS

Eight hundred thirty-four medical records were reviewed, 537 from DMP, and 279 from the PLC center. The personal health coordination was almost complete (97.8%) in the DMP, but the implementation was incomplete regarding nutrition (65.7%), dental exam (64.8%), and foot care (58.3%). Both care groups were matched for age (p = 0.056), gender (p = 0.085), duration of diabetes (p = 0.217), and basal glycemic control (p = 0.171). The DMP showed a significant net decrease in HbA1c (-0.5 [IQR 1.47%] vs -0.2 [IQR 3.05%], p = 0.0001) and LDL-c (-10 [IQR 50] vs -5 [IQR 60.5] mg/dl, p = 0.004) compared to PLC. A higher percentage of patients achieved glycemic control in the DMP than in the PLC (49.4% vs 38.7%, p = 0.038). However, both programs demonstrated similar outcomes in lipid control (28.7% vs. 30%, p = 0.695).

CONCLUSION

Despite some gaps in implementation, one year of DMP showed better glycemic control among T2DM patients compared to PLC. Both programs were comparable in terms of lipid control. Further studies identifying the gaps in care implementation could improve sustainability, future replication, and generalizability of similar programs to other healthcare systems in Saudi Arabia.

What is meant by 'integrated personalized diabetes management': A view into the future and what success should look like

Integrated personalized diabetes management (IPDM) has emerged as a promising approach to improving outcomes in patients with diabetes mellitus (DM). This care approach emphasizes the integration and coordination of different providers, including physicians, nurses, dietitians, social workers and pharmacists. The goal of IPDM is to provide patients with personalized care that is tailored to their needs. This review addresses the concept of integrated care and the use of technology (including data, software applications and artificial intelligence) as well as managerial, regulatory and financial aspects. The implementation and upscaling of digitally enabled IPDM are discussed, with elaboration of successful practices and related evidence. Finally, recommendations are made. It is concluded that the adoption of digitally enabled IPDM on a global level is inevitable, considering the challenges created by an increasing prevalence of patients with DM and the need for better outcomes and improvement of health system sustainability.

Barriers and facilitators to medical care retention for pediatric systemic lupus erythematosus in South Africa: a qualitative study

Background

Systemic lupus erythematosus (SLE) is a life-threatening, chronic, autoimmune disease requiring long term subspecialty care due to its complex and chronic nature. Childhood-onset SLE (cSLE) is more severe than adult-onset, and the cSLE population in South Africa has been reported to have an even higher risk than patients elsewhere. Therefore, it is critical to promptly diagnose, treat, and manage cSLE. In this paper, we aim to describe and evaluate barriers and enablers of appropriate long-term care of cSLE South Africa from the perspective of caregivers (parents or family members).

Methods

Caregivers (n=22) were recruited through pediatric and adult rheumatology clinics. Individuals were eligible if they cared for youth (≤19 years) who were diagnosed with cSLE and satisfied at least four of the eleven ACR SLE classification criteria.Individual in-depth, semi-structured interviews were conducted between January 2014 and December 2014, and explored barriers to and facilitators of ongoing chronic care for cSLE. Data were analyzed using applied thematic analysis.

Results

Four barriers to chronic care engagement and retention were identified: knowledge gap, financial burdens, social stigma of SLE, and complexity of the South African medical system. Additionally, we found three facilitators: patient and caregiver education, robust support system for the caregiver, and financial support for the caregiver and patient.

Conclusion

These findings highlight multiple, intersecting barriers to routine longitudinal care for cSLE in South Africa and suggest there might be a group of diagnosed children who don't receive follow-up care and are subject to attrition. cSLE requires ongoing treatment and care; thus, the different barriers may interact and compound over time with each follow-up visit. South African cSLE patients are at high risk for poor outcomes. South African care teams should work to overcome these barriers and place attention on the facilitators to improve care retention for these patients and create a model for other less resourced settings.

Effectiveness of care models for chronic disease management: A scoping review of systematic reviews

OBJECTIVE

To conduct a scoping review of models of care for chronic disease management to identify potentially effective components for management of chronic traumatic brain injury (TBI).

METHODS

Information sources: Systematic searches of three databases (Ovid MEDLINE, Embase, and Cochrane Database of Systematic Reviews) from January 2010 to May 2021.

ELIGIBILITY CRITERIA

Systematic reviews and meta-analyses reporting on the effectiveness of the Chronic Care Model (CCM), collaborative/integrated care, and other chronic disease management models.

DATA

Target diseases, model components used (n = 11), and six outcomes (disease-specific, generic health-related quality of life and functioning, adherence, health knowledge, patient satisfaction, and cost/health care use).

SYNTHESIS

Narrative synthesis, including proportion of reviews documenting outcome benefits.

RESULTS

More than half (55%) of the 186 eligible reviews focused on collaborative/integrated care models, with 25% focusing on CCM and 20% focusing on other chronic disease management models. The most common health conditions were diabetes (n = 22), depression (n = 16), heart disease (n = 12), aging (n = 11), and kidney disease (n = 8). Other single medical conditions were the focus of 22 reviews, multiple medical conditions of 59 reviews, and other or mixed mental health/behavioral conditions of 20 reviews. Some type of quality rating for individual studies was conducted in 126 (68%) of the reviews. Of reviews that assessed particular outcomes, 80% reported disease-specific benefits, and 57% to 72% reported benefits for the other five types of outcomes. Outcomes did not differ by the model category, number or type of components, or target disease.

CONCLUSIONS

Although there is a paucity of evidence for TBI per se, care model components proven effective for other chronic diseases may be adaptable for chronic TBI care.

Characteristics of self-management education and support programmes for people with chronic diseases delivered by primary care teams: a rapid review

BACKGROUND

Primary care actors can play a major role in developing and promoting access to Self-Management Education and Support (SMES) programmes for people with chronic disease. We reviewed studies on SMES programmes in primary care by focusing on the following dimensions: models of SMES programmes in primary care, SMES team's composition, and participants' characteristics.

METHODS

For this mixed-methods rapid review, we searched the PubMed and Cochrane Library databases to identify articles in English and French that assessed a SMES programme in primary care for four main chronic diseases (diabetes, cancer, cardiovascular disease and/or respiratory chronic disease) and published between 1 January 2013 and 31 December 2021. We excluded articles on non-original research and reviews. We evaluated the quality of the selected studies using the Mixed Methods Appraisal Tool. We reported the study results following the PRISMA guidelines.

RESULTS

We included 68 studies in the analysis. In 46/68 studies, a SMES model was described by focusing mainly on the organisational dimension (n = 24). The Chronic Care Model was the most used organisational model (n = 9). Only three studies described a multi-dimension model. In general, the SMES team was composed of two healthcare providers (mainly nurses), and partnerships with community actors were rarely reported. Participants were mainly patients with only one chronic disease. Only 20% of the described programmes took into account multimorbidity. Our rapid review focused on two databases and did not identify the SMES programme outcomes.

CONCLUSIONS

Our findings highlight the limited implication of community actors and the infrequent inclusion of multimorbidity in the SMES programmes, despite the recommendations to develop a more interdisciplinary approach in SMES programmes. This rapid review identified areas of improvement for SMES programme development in primary care, especially the privileged place of nurses in their promotion.

TRIAL REGISTRATION

PROSPERO 2021 CRD42021268290 .

Towards an integrated type 1 diabetes management in low-resource settings: barriers faced by patients and their caregivers in healthcare facilities in Ghana

BACKGROUND

In Low-Middle-Income Countries (LMICs), young people living with Type 1 Diabetes Mellitus (T1DM) face structural barriers which undermine adequate T1DM management and lead to poor health outcomes. However, research on the barriers faced by young people living with T1DM have mostly focused on patient factors, neglecting concerns regarding plausible barriers that may exist at the point of healthcare service delivery.

OBJECTIVE

This study sought to explore barriers faced by young people living with T1DM and their caregivers at the point of healthcare service delivery.

METHODS

Data were drawn from a qualitative research in southern Ghana. The research was underpinned by a phenomenological study design. Data were collected from 28 young people living with T1DM, 12 caregivers, and six healthcare providers using semi-structured interview guides. The data were collected at home, hospital, and support group centres via face-to-face interviews, telephone interviews, and videoconferencing. Thematic and framework analyses were done using CAQDAS (QSR NVivo 14).

RESULTS

Eight key barriers were identified. These were: shortage of insulin and management logistics; healthcare provider knowledge gaps; lack of T1DM care continuity; poor healthcare provider-caregiver interactions; lack of specialists' care; sharing of physical space with adult patients; long waiting time; and outdated treatment plans. The multiple barriers identified suggest the need for an integrated model of T1DM to improve its care delivery in low-resource settings. We adapted the Chronic Care Model (CCM) to develop an Integrated Healthcare for T1DM management in low-resource settings.

CONCLUSION

Young people living with T1DM, and their caregivers encountered multiple healthcare barriers in both in-patient and outpatient healthcare facilities. The results highlight important intervention areas which must be addressed/improved to optimise T1DM care, as well as call for the implementation of a proposed integrated approach to T1DM care in low-resource settings.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at https://professional.diabetes.org/SOC.

Association of treatment satisfaction and physician trust with glycemic control among primary care patients with type 2 diabetes in Egypt

Objectives

To evaluate the association of diabetes treatment satisfaction and trust in family physicians with glycemic control among primary care patients with type 2 diabetes mellitus.

Methods

A cross-sectional study on 319 patients with type 2 diabetes mellitus from five primary healthcare centers in Egypt. Data were collected from February to August 2021 using a structured questionnaire that contained six parts: sociodemographic data, disease profile, the Diabetes Treatment Satisfaction Questionnaire (DTSQ), 8-item Morisky Medication Adherence Scale (MMAS-8), self-reported medication knowledge questionnaire (MKQ), and revised healthcare relationship trust scale (HCR). Multiple linear regression analysis was used to assess predictors of treatment satisfaction, physician trust, and HbA1c level. P values less than 0.05 were considered significant.

Results

The mean age was 59.66 years (± 7.87 years) and 55.17% were females. Multiple linear regression analysis for predicting HbA1c showed that HbA1c level was lower in patients with higher treatment satisfaction scores (β =  - 0.289, p < 0.001) and higher medication adherence scores (β =  - 0.198, p = 0.001). Treatment satisfaction scores were positively predicted by higher physician trust scores (β = 0.301, p < 0.001), increased medication adherence scores (β = 0.160, p = 0.002), and longer duration of diabetes (β = 0.226, p < 0.001). Positive predictors for physician trust included HbA1c level (β = 0.141, p = 0.012), medication knowledge (β = 0.280, p < 0.001), diabetes treatment satisfaction (β = 0.366, p < 0.001) and medication adherence (β = 0.146, p = 0.011).

Conclusion

Optimizing diabetes treatment satisfaction and physician trust could have favorable associations with medication adherence and medication knowledge with a possible improvement in glycemic control. Family physicians should incorporate patients reported outcomes alongside traditional clinical measures in evaluating diabetes management in primary care.

Diabetic Kidney Disease Prevention Care Model Development

More than one-third of people with diabetes develop diabetic kidney disease (DKD), which substantially increases risks of kidney failure, cardiovascular disease (CVD), hypoglycemia, death, and other adverse health outcomes. A multifaceted approach incorporating self-management education, lifestyle optimization, pharmacological intervention, CVD prevention, and psychosocial support is crucial to mitigate the onset and progression of DKD. The American Diabetes Association convened an expert panel to develop the DKD Prevention Model presented herein. This model addresses prevention and treatment, including screening guidelines, diagnostic tools, and management approaches; comprehensive, holistic interventions; well-defined roles for interdisciplinary health care professionals; community engagement; and future directions for research and policy.

Assessing physical function after completing a supervised education and exercise program in adults with type 2 diabetes and exploring exercise motivation at one-year follow up: A case series study

BACKGROUND

Exercise programs for adults with type 2 diabetes (T2D) improve glycemic control and physical function. However, diabetes complications, disability, and motivation pose challenges for exercise participation.

OBJECTIVE

The purpose of the study was to: 1) measure change in fasting blood glucose, blood pressure, anthropometrics (i.e. BMI and waist circumference), and physical function (i.e. endurance, agility and balance, upper and lower-body strength and flexibility) after completing an eight-week education and exercise program for adults with T2D; and 2) explore the experience of exercise continuation in people living with T2D at one-year follow-up.

METHODS

A mixed methods case series design was conducted. Participants were ≥ 18 years and had a clinical diagnosis of T2D (glycated hemoglobin (A1C) ≥ 6.5%). Participants completed two one-hour exercise sessions and one one-hour education session per week for eight weeks. Blood glucose, blood pressure, body mass index (BMI), waist circumference, and physical function were measured at baseline and after completing the program. Follow-up telephone interviews were conducted at one, six, and 12-months and thematic analysis was employed to analyze interviews.

RESULTS

Twelve participants completed the program. Clinically significant improvements were observed for waist circumference, systolic blood pressure, six-minute walk test (6MWT), timed up-and-go test (TUG), 30-second chair stand test (CST) and arm curls. Three themes emerged from the interviews that described participant reflections and experiences with a supervised education and exercise program for management of their T2D: 1) medical management; 2) lifestyle management; and 3) finding what works. Conclusion: Supervised programming improves physical function and may mitigate disability. Physiotherapists are qualified to assess and treat physical function through education and exercise.

Australian general practitioners' perspectives on integrating specialist diabetes care with primary care: qualitative study

BACKGROUND

Improving the coordination and integration of health services is recognised nationally and internationally as a key strategy for improving the quality of diabetes care. The Australian Diabetes Alliance Program (DAP) is an integrated care model implemented in the Hunter New England Local Health District (HNELHD), New South Wales (NSW), in which endocrinologists and diabetes educators collaborate with primary care teams via case-conferencing, practice performance review, and education sessions. The objective of this study was to report on general practitioners' (GPs) perspectives on DAP and whether the program impacts on their skills, knowledge, and approach in delivering care to adult patients with type 2 diabetes.

METHODS

Four primary care practices with high rates of monitoring haemoglobin A1c (HbA1c) levels (> 90% of patients annually) and five practices with low rates of monitoring HbA1c levels (< 80% of patients annually) from HNELHD, NSW provided the sampling frame. A total of nine GPs were interviewed. The transcripts from the interviews were reviewed and analysed to identify emergent patterns and themes.

RESULTS

Overall, GPs were supportive of DAP. They considered that DAP resulted in significant changes in their knowledge, skills, and approach and improved the quality of diabetes care. Taking a more holistic approach to care, including assessing patients with diabetes for co-morbidities and risk factors that may impact on their future health was also noted. DAP was noted to increase the confidence levels of GPs, which enabled active involvement in the provision of diabetes care rather than referring patients for tertiary specialist care. However, some indicated the program could be time consuming and greater flexibility was needed.

CONCLUSIONS

GPs reported DAP to benefit their knowledge, skills and approach for managing diabetes. Future research will need to investigate how to improve the intensity and flexibility of the program based on the workload of GPs to ensure long-term acceptability of the program.

Religion, spirituality and improved glycemic control among people with type 2 diabetes: A systematic review

OBJECTIVE

This systematic review investigates the association between measures of religiosity or spirituality (R/S) and glycemic control in patients with type 2 diabetes.

METHODS

A systematic literature review was conducted for all English language articles published between 1966 and August 2022 in six relevant databases: PubMed, PSYCHinfo, CINAHL, ATLA, Scopus, Sociological Abstracts, and the Cochrane Central Register of Controlled Clinical Trials. Search terms for religious variables included, "religion", "religiosity", "spirituality", "religious attendance". Search terms for diabetes outcomes included, "diabetes", "hemoglobin A1c", "blood glucose", "glycemic control." The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

A total of 758 studies examining correlations between R/S and glycemic control were screened from relevant databases. Forty studies were evaluated for eligibility and inclusion. Eight studies were selected and analyzed. Three studies showed positive associations, two studies showed positive and neutral associations, two studies showed positive and negative associations, and one study showed a neutral association. Limitations included small sample sizes and heterogeneity of study designs.

CONCLUSION

Involvement in religious and spiritual practices may be associated with improved glycemic control in patients with type 2 diabetes. Specific mechanisms for associations may be partially explained by more effective self-management practices, increased positive social contacts, and regular community support. Further research is needed to clarify these associations.

Adoption of Electronic Medical Records for Chronic Disease Care in Kenyan Refugee Camps: Quantitative and Qualitative Prospective Evaluation

Background

Noncommunicable disease (NCD) prevention and control in humanitarian emergencies is a well-recognized need, but there is little evidence to guide responses, leading to varying care delivery. The Sana.NCD mobile health (mHealth) app, initially developed in Lebanon, is the only known mHealth tool for NCD management designed to increase care quality and coverage for providers in humanitarian settings.

Objective

We evaluated a specialized mHealth app consisting of an abbreviated medical record for patients with hypertension or diabetes, adapted for a Kenyan refugee camp setting.

Methods

We tested an adapted version of the Sana.NCD app (diabetes and hypertension medical record) in an 11-month (May 2021 to March 2022) quantitative and qualitative prospective evaluation in Kenya's Hagadera refugee camp. Leveraging the rollout of a general electronic medical record (EMR) system in the Kakuma refugee camp, we compared a specialized NCD management app to a general EMR. We analyzed secondary data collected from the Sana.NCD app for 1539 patients, EMR data for 68 patients with NCD from Kakuma's surgical and outpatient departments, and key informant interviews that focused on Hagadera clinic staff perceptions of the Sana.NCD app.

Results

The Hagadera NCD clinic reported 18,801 consultations, 42.1% (n=7918) of which were reported in the NCD app. The Kakuma EMR reported 350,776 visits, of which 9385 (2.7%) were for NCDs (n=4264, 1.2% hypertension; n=2415, 0.7% diabetes). The completeness of reporting was used as a quality-of-care metric. Age, sex, prescribed medicines, random blood sugar, and smoking status were consistently reported in both the NCD app (>98%) and EMR (100%), whereas comorbidities, complications, hemoglobin A1c, and diet were rarely reported in either platform (≤7% NCD app; 0% EMR). The number of visits, BMI, physical activity, and next visit were frequently reported in the NCD app (≥99%) but not in the EMR (≤15%). In the NCD app, the completeness of reporting was high across the implementation period, with little meaningful change. Although not significantly changed during the study, elevated blood sugar (P=.82) and blood pressure (P=.12) were reported for sizable proportions of patients in the first (302/481, 62.8%, and 599/1094, 54.8%, respectively) and last (374/602, 62.1%, and 720/1395, 51.6%, respectively) study quarters. Providers were satisfied with the app, as it standardized patient information and made consultations easier. Providers also indicated that access to historic patient information was easier, benefiting NCD control and follow-up.

Conclusions

A specialized record for NCDs outperformed a more general record intended for use in all patients in terms of reporting completeness. This CommCare-based NCD app can easily be rolled out in similar humanitarian settings with minimal adaptation. However, the adaptation of technologies to the local context and use case is critical for uptake and ensuring that workflows and time burden do not outweigh the benefits of EMRs.

The Mediation Effect of Attitude on the Association Between Knowledge and Self-Management Behaviors in Chinese Patients With Diabetes

Objective: This study aims to investigate the level of knowledge, attitude and self-management behaviors of diabetic patients, to explore the mediating role of attitude in the relationship between knowledge and self-management behaviors. Methods: 900 diabetes patients were randomly selected from the eastern, central and western regions of Shandong Province, China, and recovered 863 valid questionnaires. Path analysis was used to examine the mediating role of attitude in the relationship between knowledge and self-management behaviors in patients with diabetes. Results: The mean score (SD) of the diabetes self-management questionnaire (DSMQ) in this study was 35.01 (6.87). The direct effect value of knowledge level on self-management behaviors was 0.357, accounting for 62.09% of the total effect. The indirect effect value of knowledge on self-management behaviors through attitude was 0.218, accounting for 37.91%. Conclusion: Level of knowledge has a significant direct impact on self-management behaviors and an indirect impact on self-management behaviors through attitude. Therefore, it is necessary to strengthen health education on diabetes to improve awareness, ameliorate attitudes toward diabetes, and change self-management behaviors.

Cardiorenal care coordination: holistic patient care opportunities in the primary care setting for patients with chronic kidney disease and atherosclerotic cardiovascular disease

OBJECTIVES

Chronic kidney disease (CKD) and atherosclerotic cardiovascular disease (ASCVD) are closely linked conditions, and the presence of each condition promotes incidence and progression of the other. In this study, we sought to better understand the medical journey of patients with CKD and ASCVD and to uncover patients' and healthcare providers' (HCPs) perceptions and attitudes toward CKD and ASCVD diagnosis, treatment, and care coordination.

METHODS

Cross-sectional, US-population-based online surveys were conducted between May 18, 2021, and June 17, 2021, among 239 HCPs (70 of whom were primary care physicians, or PCPs) and 195 patients with CKD and ASCVD.

RESULTS

PCPs reported personally diagnosing CKD in 78% and ASVD in 64% of their patients, respectively. PCPs reported they are more likely to serve as the overall coordinator of their patient's care (89%), while slightly more than half of PCPs self-identified as a patient's coordinator of care specifically for CKD (54%) or ASCVD (59%). In contrast, patients viewed their PCP as their coordinator of care for CKD (25%) or ASCVD (9%). PCPs who personally treated patients with CKD and ASCVD most often recalled primarily prescribing or recommending pharmacologic treatments for CKD and ASCVD; however, patients reported that lifestyle modification was the most common treatment modality they had ever used to manage CKD and ASCVD.

CONCLUSION

CKD and ASCVD are interrelated cardiometabolic conditions with underlying risk factors that can be managed in a primary care setting. However, few patients in our study considered their PCP to be the coordinator of their care for CKD or ASCVD. PCPs can and should take a more active role in educating patients and coordinating care for those with CKD and ASCVD.

Clinical outcomes of a digitally supported approach for self-management of type 2 diabetes mellitus

Background

Self-management of Type 2 diabetes mellitus (T2D) is challenging. Regular self-monitoring of blood glucose and healthy lifestyles are required to improve glycometabolic control, thus delaying diabetes complications, and reducing hospitalizations. Digital technologies can empower patients in their disease management promoting self-management and motivation to change behaviors. We report the results of an exploratory trial aimed at evaluating the metabolic outcomes of using digital solutions for T2D self-management developed in the ProEmpower project, a European Commission funded Pre-Commercial Procurement.

Methods

Two digital solutions, DM4All and DiaWatch, which were codesigned with providers, patients, and caregivers, enabled the collection of clinical parameters by the patient using a smartphone integrated with the medical devices (glucometer, sphygmomanometer, scale, smart watch for heart rate monitoring and step counter). Data were automatically sent to the shared care plan allowing professionals to monitor adherence to treatment, set goals, and communicate more effectively with patients. At baseline and after an average follow-up of 8 months, glycosylated hemoglobin (HbA1c), body weight, blood pressure, and blood lipids were measured in 100 T2D patients using the ProEmpower solutions across different diabetes centers in Campania Region, age 45-79  years, both genders, and compared with a Control cohort of T2D patients (n = 100) with similar clinical characteristics and followed for a comparable period of observation in the same centers.

Results

At baseline, the ProEmpower participants and the Control subjects were on average overweight, with a similar BMI in the two cohorts, and mean HbA1c was at acceptable levels (around 7.0%). After the 8 month exploratory trial, body weight, HbA1c, systolic and diastolic blood pressure, and plasma and LDL-cholesterol significantly decreased in the ProEmpower participants compared to baseline (p < 0.05 for all). The changes in systolic and diastolic blood pressure, and plasma and LDL-cholesterol were significantly different from those observed in the Control cohort (p < 0.05 for all).

Conclusion

This pilot study showed positive effects on metabolic outcomes relevant to cardiovascular risk in T2D of adopting digital telemedicine self-monitoring solutions based on automation of measurements and coaching on healthy lifestyles promotion.

The association between Patient Assessment of Chronic Illness Care Scores and quality of life in type 2 diabetes patients

Background

Chronic illness care is an important factor for health promotion in diabetes since it affects health outcomes such as quality of life.

Aims

The aim of this study was to investigate the relationship between the Patient Assessment of Chronic Illness Care and the quality of life in type 2 diabetes patients.

Methods

The study used a cross-sectional and correlational design. The sample included 317 patients with type 2 diabetes. A socio-demographic and disease-related questionnaire form, the Patient Assessment of Chronic Illness Care (PACIC) scale and the WHOQOL-BREF Quality of Life Scale were used to collect data.

Results

According to the regression analysis, the stronger predictor affecting all domains of quality of life was the overall PACIC. This study demonstrated the importance of satisfaction level of chronic illness care in the improvement of quality of life. Therefore, the factors affecting the satisfaction level with chronic care services should be determined to improve the quality of life of patients. In addition, healthcare based on the chronic-care model should be provided in the care of the patients.

Conclusions

PACIC had an important effect on quality of life of the patients. This study demonstrated the importance of satisfaction level on chronic illness care in the improvement of quality of life.

Harnessing an Integrated Health Communication (IHC) Framework for Campaigns: A Case of Prescription Drug Decision Making

Drawing on a multiplicity of mass media and health behavior theories, we propose an integrated health communication (IHC) framework to understand and leverage the ways in which mass mediated and interpersonal sources of health information influence the public's health behavior in the context of their prescription drug decisions. Building on the agenda setting theory, two-step flow theory, and the Health Belief Model, we dig into the interrelationships between mass media and interpersonal information sources and information seeking engagement. Employing survey methodology, our framework was tested using a sample of U.S. adults (N = 628). The major results include (a) information gained through interpersonal sources and perceived benefits of the prescription drugs positively and sequentially mediate the association between mass media exposure and intent to seek prescription drug information, (b) interpersonal health information positively moderate the mediation of mass media exposure - perceived benefits - intent to seek prescription drug information, and (c) the inexpert interpersonal information's positive interaction effect with mass media exposure on intent to seek prescription drug information mediated through perceived benefits was greater with high expert interpersonal communication. These results impart valuable theoretical contributions and have the potential to guide integrated health communication (IHC) campaigns.

Elements Characterising Multicomponent Interventions Used to Improve Disease Management Models and Clinical Pathways in Acute and Chronic Heart Failure: A Scoping Review

This study aimed to summarise different interventions used to improve clinical models and pathways in the management of chronic and acute heart failure (HF). A scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. MEDLINE (via PubMed), Embase, The Cochrane Library, and CINAHL were searched for systematic reviews (SR) published in the period from 2014 to 2019 in the English language. Primary articles cited in SR that fulfil inclusion and exclusion criteria were extracted and examined using narrative synthesis. Interventions were classified based on five chosen elements of the Chronic Care Model (CCM) framework (self-management support, decision support, community resources and policies, delivery system, and clinical information system). Out of 155 SRs retrieved, 7 were considered for the extraction of 166 primary articles. The prevailing setting was the patient's home. Only 46 studies specified the severity of HF by reporting the level of left ventricular ejection fraction (LVEF) impairment in a heterogeneous manner. However, most studies targeted the populations with LVEF ≤ 45% and LVEF < 40%. Self-management and delivery systems were the most evaluated CCM elements. Interventions related to community resources and policy and advising/reminding systems for providers were rarely evaluated. No studies addressed the implementation of a disease registry. A multidisciplinary team was available with similarly low frequency in each setting. Although HF care should be a multi-component model, most studies did not analyse the role of some important components, such as the decision support tools to disseminate guidelines and program planning that includes measurable targets.

Programa de diabetes: improving diabetes care for undocumented immigrants using the Chronic Care Model at a free community clinic

AIMS

This study examined whether the Chronic Care Model can be successfully applied to improve health outcome measures for uninsured, undocumented immigrants with diabetes at a free, non-federally funded community clinic.

METHODS

Data were collected from 128 uninsured, undocumented immigrants enrolled in Programa de diabetes, a comprehensive diabetes program at People's Health Clinic based on the six core elements of the Chronic Care Model. All study participants self-identified by the Hispanic ethnicity. A longitudinal study design was used to compare baseline diabetic health measures with outcome data after patient program participation over a 12-month enrollment period. Linear mixed effect model was used to determine the patient specific change in HbA1C across time, controlling for gender, age, food insecurity, income level, diabetes type, and literacy. In addition, McNemar tests were conducted to compare the coverage of eye exams and statin use before and after program enrollment.

RESULTS

After program enrollment, individual specific change in HbA1C was expected to be - 0.201 [95% CI 0.244, - 0.158] % per month after controlling for baseline covariates. There were statistically significant improvements in both eye exam coverage (p < 0.01) and statin use (p < 0.01).

CONCLUSIONS

The Chronic Care Model can be successfully applied to improve health outcome measures at a free, non-federally funded community clinic among uninsured, undocumented immigrants, who identify by the Hispanic ethnicity and have the diagnosis of diabetes. Barriers to care including food insecurity, federal poverty level and illiteracy do not preclude glycemic control.

Multilevel influences on patient engagement and chronic care management

OBJECTIVES

Physician practices are increasingly owned by health systems, which may support or hinder adoption of innovative care processes for adults with chronic conditions. We examined health system- and physician practice-level capabilities associated with adoption of (1) patient engagement strategies and (2) chronic care management processes for adult patients with diabetes and/or cardiovascular disease.

STUDY DESIGN

We analyzed data collected from the National Survey of Healthcare Organizations and Systems, a nationally representative survey of physician practices (n = 796) and health systems (n = 247) (2017-2018).

METHODS

Multivariable multilevel linear regression models estimated system- and practice-level characteristics associated with practice adoption of patient engagement strategies and chronic care management processes.

RESULTS

Health systems with processes to assess clinical evidence (β = 6.54 points on a 0-100 scale; P = .004) and with more advanced health information technology (HIT) functionality (β = 2.77 points per SD increase on a 0-100 scale; P = .03) adopted more practice-level chronic care management processes, but not patient engagement strategies, compared with systems lacking these capabilities. Physician practices with cultures oriented to innovation, more advanced HIT functionality, and with a process to assess clinical evidence adopted more patient engagement strategies and chronic care management processes.

CONCLUSIONS

Health systems may be better able to support the adoption of practice-level chronic care management processes, which have a strong evidence base for implementation, compared with patient engagement strategies, which have less evidence to guide effective implementation. Health systems have an opportunity to advance patient-centered care by expanding practice-level HIT functionality and developing processes to appraise clinical evidence for practices.

Improving Diabetes Care Through Population Health Innovations and Payments: Lessons from Western Maryland

BACKGROUND

Global budgets might incentivize healthcare systems to develop population health programs to prevent costly hospitalizations. In response to Maryland's all-payer global budget financing system, University of Pittsburgh Medical Center (UPMC) Western Maryland developed an outpatient care management center called the Center for Clinical Resources (CCR) to support high-risk patients with chronic disease.

OBJECTIVE

Evaluate the impact of the CCR on patient-reported, clinical, and resource utilization outcomes for high-risk rural patients with diabetes.

DESIGN

Observational cohort study.

PARTICIPANTS

One hundred forty-one adult patients with uncontrolled diabetes (HbA1c > 7%) and one or more social needs who were enrolled between 2018 and 2021.

INTERVENTIONS

Team-based interventions that provided interdisciplinary care coordination (e.g., diabetes care coordinators), social needs support (e.g., food delivery, benefits assistance), and patient education (e.g., nutritional counseling, peer support).

MAIN MEASURES

Patient-reported (e.g., quality of life, self-efficacy), clinical (e.g., HbA1c), and utilization outcomes (e.g., emergency department visits, hospitalizations).

KEY RESULTS

Patient-reported outcomes improved significantly at 12 months, including confidence in self-management, quality of life, and patient experience (56% response rate). No significant demographic differences were detected between patients with or without the 12-month survey response. Baseline mean HbA1c was 10.0% and decreased on average by 1.2 percentage points at 6 months, 1.4 points at 12 months, 1.5 points at 18 months, and 0.9 points at 24 and 30 months (P<0.001 at all timepoints). No significant changes were observed in blood pressure, low-density lipoprotein cholesterol, or weight. The annual all-cause hospitalization rate decreased by 11 percentage points (34 to 23%, P=0.01) and diabetes-related emergency department visits also decreased by 11 percentage points (14 to 3%, P=0.002) at 12 months.

CONCLUSIONS

CCR participation was associated with improved patient-reported outcomes, glycemic control, and hospital utilization for high-risk patients with diabetes. Payment arrangements like global budgets can support the development and sustainability of innovative diabetes care models.

Self-management in heart failure using mHealth: A content validation

AIM

To describe the development of a mobile health application -mICardiApp- designed by a multidisciplinary professional team and patients with heart failure and to evaluate its content validity.

METHODS

Critical reviews of the literature, semi-structured interviews with patients, and user stories guided the development of the content of the mobile application. These contents were refined and validated through a modified Delphi process. An expert panel of healthcare and social care professionals together with patients and academics evaluated the content through two content validity indicators, relevance, and adequacy, and provided narrative feedback. The content validity of the app and each screen was determined by calculating the Content Validity Index (CVI). Similarly, the Adequacy Index (AI) was analyzed.

RESULTS

The developed app is composed by 8 topics: (1) available resources, (2) cardiac rehabilitation, (3) control of signs and symptoms, (4) emotional support, (5) learning and having fun, (6) medication, (7) nutrition, and (8) physical activity. The results demonstrated high CVI of the screens and the full app. 57 of the 59 screens in the app reached an excellent CVI ≥ 0.70 for both relevance and adequacy, except for 2 screens. The CVI Average Method of the app was 0.851.

CONCLUSIONS

mICardiApp is presented as an application to improve health literacy and self-management of patients with multimorbidity and heart failure, with proven validation.

Electronic health records in nursing from 2000 to 2020: A bibliometric analysis

Background

Electronic health records (EHR) is the longitudinal data generated by patients in medical institutions and recorded by electronic medical information systems in the form of digital, which is also the most widespread application of big data in medicine. The purpose of this study was to explore the application of electronic health records in the field of nursing and determine the current research status and hotspots.

Methods

A bibliometric analysis of electronic health records in nursing was undertaken from 2000 to 2020. The literature comes from Web of Science Core Collection database. We used CiteSpace (version 5.7 R5; Drexel University), which is a Java-based software that especially visualized collaborative networks and research topics.

Results

A total of 2616 publications were included in the study. We found that publications increased year by year. The Journal of American Medical Informatics Association (n = 921) is the most cited. The United States (n = 1,738) has the most publications in this field. University Penn (n = 63) is the institution with the most publications. There is no influential cooperation network among the authors, of which Bates, David W (n = 12) have the largest number of publications. The relevant publications also focus on the fields of health care science and services, and medical informatics. In keywords, EHR, long-term care, mobile application, inpatient falls, and advance care planning has been researching hotspots in recent years.

Conclusion

With the popularization of information systems, the publications of EHR in the nursing field have increased year by year. This study provides the basic structure, potential cooperation, and research trends of EHR in the field of nursing from 2000 to 2020, and provides a reference for nurses to effectively use EHR to help clinical work or scientific researchers explore the potential significances of EHR.

A patient-centered comparative effectiveness research study of culturally appropriate options for diabetes self-management

This project compared the effectiveness of two evidence-based models of culturally competent diabetes health promotion: The Diabetes Self-Management Support Empowerment Model (DSMS), and The Chronic Care Model (CCM). Our primary outcome was improvement in patient capacity for diabetes self-management as measured by the Diabetes Knowledge Questionnaire (DKQ) and the Patient Activation Measure (PAM). Our secondary outcome was patient success at diabetes self-management as measured by improvement in A1c, depression sores using the PHQ-9, and Body Mass Index (BMI). We also gathered data on the cultural competence of the program using the Consumer Assessment of Healthcare Providers and Systems Cultural Competence Set (CAHPS-CC). We compared patient outcomes in two existing sites in Albuquerque, New Mexico that serve a large population of Latino diabetes patients from low-income households. Participants were enrolled as dyads-a patient participant (n=226) and a social support participant (n=226). Outcomes over time and by program were analyzed using longitudinal linear mixed modeling, adjusted for patient participant demographic characteristics and other potential confounding covariates. Secondary outcomes were also adjusted for potential confounders. Interactions with both time and program helped to assess outcomes. This study did not find a difference between the two sites with respect to the primary outcome measures and only one of the three secondary outcomes showed differential results. The main difference between programs was that depression decreased more for CCM than for DSMS. An exploratory, subgroup analysis revealed that at CCM, patient participants with a very high A1c (>10) demonstrated a clinically meaningful decrease. However, given the higher cultural competence rating for the CCM, statistically significant improvement in depression, and the importance of social support to the patients, results suggest that a culturally and contextually situated diabetes self-management and education program design may deliver benefit for patients, especially for patients with higher A1c levels.

The Natural Helper approach to culturally responsive disease management: protocol for a type 1 effectiveness-implementation cluster randomised controlled trial of a cultural mentor programme

INTRODUCTION

Chronic disease is a leading cause of death and disability that disproportionately burdens culturally and linguistically diverse (CALD) communities. Self-management is a cornerstone of effective chronic disease management. However, research suggests that patients from CALD communities may be less likely to engage with self-management approaches. The Natural Helper Programme aims to facilitate patient engagement with self-management approaches (ie, 'activation') by embedding cultural mentors with lived experience of chronic disease into chronic disease clinics/programmes. The Natural Helper Trial will explore the effect of cultural mentors on patient activation, health self-efficacy, coping efforts and health-related quality of life (HRQoL) while also evaluating the implementation strategy.

METHODS AND ANALYSIS

A hybrid type-1 effectiveness-implementation cluster-randomised controlled trial (phase one) and a mixed-method controlled before-and-after cohort extension of the trial (phase 2). Hospital clinics in highly multicultural regions in Australia that provide healthcare for patients with chronic and/or complex conditions, will participate. A minimum of 16 chronic disease clinics (clusters) will be randomised to immediate (active arm) or delayed implementation (control arm). In phase 1, the active arm will receive a multifaceted strategy supporting them to embed cultural mentors in their services while the control arm continues with usual care. Each cluster will recruit an average of 15 patients, assessed at baseline and 6 months (n=240). In phase 2, clusters in the control arm will receive the implementation strategy and evaluate the intervention on an additional 15 patients per cluster, while sustainability in active arm clusters will be assessed qualitatively. Change in activation over 6 months, measured using the Patient Activation Measure will be the primary effectiveness outcome, while secondary effectiveness outcomes will explore changes in chronic disease self-efficacy, coping strategies and HRQoL. Secondary implementation outcomes will be collected from patient-participants, mentors and healthcare providers using validated questionnaires, customised surveys and interviews aligning with the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate acceptability, reach, dose delivered, sustainability, cost-utility and healthcare provider determinants.

ETHICS AND DISSEMINATION

This trial has full ethical approval (2021/ETH12279). The results from this hybrid trial will be presented at scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12622000697785.

Evaluation of pharmacist consults within a collaborative enhanced primary care team model to improve diabetes care

BACKGROUND

An enhanced primary care team model was implemented to provide proactive, longitudinal care to patients with diabetes, grounded in close partnership between primary care providers (PCPs), nurses, and Medication Management Services (MMS) pharmacists. The purpose of this study is to evaluate the impact of the MMS pharmacist involvement in the enhanced primary care model for patients with diabetes.

METHODS

This retrospective cohort study compared the quality of diabetes care between patients referred to a pharmacist and propensity score matched controls who were not. Eligible patients were adults (age 18 to 75 years) enrolled in the enhanced primary care team process who did not meet at least one of four diabetes quality indicators at 13 Mayo Clinic Rochester primary care practice locations. The intervention examined was asynchronous e-consults by pharmacists affiliated with the primary care practice.

MAIN MEASURES

The primary outcome was change in the proportion of patients meeting the composite of four diabetes treatment goals (D4), including hemoglobin A1c (HbA1c) control, blood pressure control, aspirin use, and statin use at six months from enrollment among patients who received pharmacist intervention compared to matched patients who did not. Secondary outcomes were each of the D4 goal individually.

RESULTS

The proportion of patients meeting the D4 increased with pharmacist e-consults (N = 85) compared to matched controls with no review (N = 170) (27% vs 7.0%, p<0.001). The change in patients meeting treatment goals of HbA1c (12.9% vs 4.1%, p = 0.020), blood pressure (9.4% vs 2.4%, p = 0.023), aspirin use (10.6% vs 2.9%, p = 0.018), and statin use (17.6% vs -1.2%, p<0.001) all increased with pharmacist e-consults.

CONCLUSIONS

Pharmacist engagement in the enhanced primary care team improved diabetes management. This supports the inclusion and utilization of pharmacists in multidisciplinary efforts to improve diabetes care.

Patient Assessment Chronic Illness Care (PACIC) and its associations with quality of life among Swiss patients with systemic sclerosis: a mixed methods study

BACKGROUND

The Chronic Care Model (CCM) is a longstanding and widely adopted model guiding chronic illness management. Little is known about how CCM elements are implemented in rare disease care or how patients' care experiences relate to health-related quality of life (HRQoL). We engaged patients living with systemic sclerosis (SSc) to assess current care according to the CCM from the patient perspective and their HRQoL.

METHODS

We employed an explanatory sequential mixed methods design. First, we conducted a cross-sectional quantitative survey (n = 101) using the Patient Assessment of Chronic Illness Care (PACIC) and Systemic Sclerosis Quality of Life (SScQoL) questionnaires. Next, we used data from individual patient interviews (n = 4) and one patient focus group (n = 4) to further explore care experiences of people living with SSc with a focus on the PACIC dimensions.

RESULTS

The mean overall PACIC score was 3.0/5.0 (95% CI 2.8-3.2, n = 100), indicating care was 'never' to 'generally not' aligned with the CCM. Lowest PACIC subscale scores related to 'goal setting/tailoring' (mean = 2.5, 95% CI 2.2-2.7) and 'problem solving/contextual counselling' (mean = 2.9, 95% CI 2.7-3.2). No significant correlations were identified between the mean PACIC and SScQoL scores. Interviews revealed patients frequently encounter major shortcomings in care including 'experiencing organized care with limited participation', 'not knowing which strategies are effective or harmful' and 'feeling left alone with disease and psychosocial consequences'. Patients often responded to challenges by 'dealing with the illness in tailored measure', 'taking over complex coordination of care' and 'relying on an accessible and trustworthy team'.

CONCLUSIONS

The low PACIC mean overall score is comparable to findings in patients with common chronic diseases. Key elements of the CCM have yet to be systematically implemented in Swiss SSc management. Identified gaps in care related to lack of shared decision-making, goal-setting and individual counselling-aspects that are essential for supporting patient self-management skills. Furthermore, there appears to be a lack of complex care coordination tailored to individual patient needs.

4. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Ensuring Equitable Care in Diabetes Management Among Patients of Health Resources & Services Administration-Funded Health Centers in the United States

AIM

To explore whether there are racial/ethnic differences in diabetes management and outcomes among adult health center (HC) patients with type 2 diabetes.

METHODS

We analyzed data from the 2014 Health Center Patient Survey, a national sample of HC patients. We examined indicators of diabetes monitoring (A1C testing, annual foot/eye doctor visits, and cholesterol checks) and care management (specialist referrals, individual treatment plan, and receipt of calls/appointments/home visits). We also examined diabetes-specific outcomes (blood glucose levels, diabetes-related emergency department [ED] visits/hospitalizations, and diabetes self-management confidence) and general outcomes (number of doctor visits, ED visits, and hospitalizations). We used multilevel logistic regression models to examine racial/ethnic disparities by the above indicators.

RESULTS

We found racial/ethnic parity in A1C testing, eye doctor visits, and diabetes-specific outcomes. However, Hispanics/Latinos (odds ratio [OR] 0.26), non-Hispanic African Americans (OR 0.25), and Asians (OR 0.11) were less likely to receive a cholesterol check than Whites. Non-Hispanic African Americans (OR 0.43) were less likely to have frequent doctor visits, while Hispanic/Latino patients (OR 0.45) were less likely to receive an individual treatment plan.

CONCLUSION

HCs largely provide equitable diabetes care but have room for improvement in some indicators. Tailored efforts such as culturally competent care and health education for some racial/ethnic groups may be needed to improve diabetes management and outcomes.

A New Look at Barriers to Clinical Care Among Appalachian Residents Living With Diabetes

In the United States, diabetes is the seventh leading cause of death and continues to rise in prevalence, with type 2 diabetes accounting for 90-95% of all cases. Rates of diabetes in Kentucky, and, in particular, the Appalachian region, are among the highest in the nation and are increasing faster than the national average. Despite this disproportionate burden, barriers to clinical appointment attendance have not been fully explored in this population. This article examines the association among perceived barriers to clinical attendance, glycemic control, and diabetes self-care as part of an ongoing study. We used a 25-item checklist developed using the Chronic Care Model to assess participants' barriers to clinic attendance. Glycemic control was assessed via A1C measurement. Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities measure. At the time of analysis, 123 of the 356 participants (34.6%) did not report any barriers to clinic attendance. For the remainder, the major reported barriers included forgetting appointments, inability to afford medicines or other treatment, and placing faith above medical care. The average A1C was 7.7%, and the average diabetes self-care summary score was 17.1 out of 35 points (with higher values indicating better self-care). Missing clinic appointments is associated with lower health outcomes, especially in vulnerable populations. This study can help educate clinic staff on perceived barriers to type 2 diabetes management among people with diabetes in Appalachia.

No Substitute for Hard Work: Dedication to the Diabetes Community

This article is adapted from a speech Dr. Kirksey delivered in June 2022 as President, Health Care & Education of the American Diabetes Association. He delivered his address at the Association's 82nd Scientific Sessions in New Orleans, LA. A webcast of this speech is available for viewing on the DiabetesPro website (https://professional.diabetes.org/webcast/president-health-care-education-address-and-outstanding-educator-diabetes-award-lecture).

1. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis

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 (HbA_1c), 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 HbA_1c, 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 HbA_1c 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 HbA_1c ≥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 HbA_1c is ≥8% and with interventions containing four or more CCM elements.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO  CRD42021273959.

Preferring self-management behavior of patients with chronic kidney disease

This study explores the preferred behavior of self-management among chronic kidney disease (CKD) patients and offers suggestions for different patients from personalized medicine. According to some related references, a questionnaire was designed in 2020 to collect data from 131 patients with CKD in a general hospital. The Sampling patients showed no difference in their disease progress. The questionnaire covered two aspects of demographic and behavior with 29 items on six dimensions. Statistical methods such as a descriptive analysis of the F test in behavior dimensions on demographic characteristics and Principal component analysis from items have been applied to classify some kinds of self-management behavior into different groups. In the demographic insight, employment status closely relates to self-management behavior, and income is insignificant. In the behavior aspects, according to some key items, we found four types of self-management behavior preferred in the sorting: cognitive-knowledge, Diet-exercise-medical, emotion management, and exercise-medical, which were defined by behavior dimensions. Although patients had the same disease progress, their self-management behavior mainly existed in four types based on critical factors. According to their favorite behavior and personality group, healthcare stakeholders can offer lean support for improving patients' self-management of CKD in China.

Clinical complexity and diabetes: a multidimensional approach for the management of cardiorenal metabolic syndrome

Diabetes mellitus (DM) is one of the fastest-growing health emergencies of the 21st century, and one of the chronic diseases with the highest socio-economic impact on health care systems. DM is the main cause of chronic kidney disease, and is associated with a significant increase in cardiovascular risk and clinical and care complexity. The presence of a constellation of cardiac, metabolic, and renal diseases, in a complex patient with DM, constitutes the CardioRenal Metabolic Syndrome (CRMS). The management of these patients should include a paradigm shift from a reactive strategy to a proactive approach, and the integration of territorial, hospital and social assistance services according to the Chronic Care Model (CCM). Complexity science suggests an alternative model in which disease and health arise from complex, dynamic, and unique interactions among the different components of the overall system. The hospital should be viewed as a highly specialized hub of the chronic care system, which interacts with the outpatient specialist and primary care. In order to create effective communication among territorial care units and highly specialized hospitals, levels of clinical complexity are here proposed and included in a multidimensional management model for the complex patient with diabetes and cardiorenal comorbidity.

Evaluation of an Enhanced Primary Care Team Model to Improve Diabetes Care

PURPOSE

Primary care practices manage most patients with diabetes and face considerable operational, regulatory, and reimbursement pressures to improve the quality of this care. The Enhanced Primary Care Diabetes (EPCD) model was developed to leverage the expertise of care team nurses and pharmacists to improve diabetes care.

METHODS

Using a retrospective, interrupted-time series design, we evaluated the EPCD model's impact on D5, a publicly reported composite quality measure of diabetes care: glycemic control, blood pressure control, low-density lipoprotein control, tobacco abstinence, and aspirin use. We examined 32 primary care practices in an integrated health care system that cares for adults with diabetes; practices were categorized as staff clinician practices (having physicians and advanced practice providers) with access to EPCD (5,761 patients); resident physician practices with access to EPCD (1,887 patients); or staff clinician practices without access to EPCD (10,079 patients). The primary outcome was the percentage of patients meeting the D5 measure, compared between a 7-month preimplementation period and a 10-month postimplementation period.

RESULTS

After EPCD implementation, staff clinician practices had a significant improvement in the percentage of patients meeting the D5 composite quality indicator (change in incident rate ratio from 0.995 to 1.005; P = .01). Trends in D5 attainment did not change significantly among the resident physician practices with access to EPCD (P = .14) and worsened among the staff clinician practices without access to EPCD (change in incident rate ratio from 1.001 to 0.994; P = .05).

CONCLUSIONS

Implementation of the EPCD team model was associated with an improvement in diabetes care quality in the staff clinician group having access to this model. Further study of proactive, multidisciplinary chronic disease management led by care team nurses and integrating clinical pharmacists is warranted.

Development and operationalization of a data framework to assess quality of integrated diabetes care in the fragmented data landscape of Belgium

Background

To assess the quality of integrated diabetes care, we should be able to follow the patient throughout the care path, monitor his/her care process and link them to his/her health outcomes, while simultaneously link this information to the primary care system and its performance on the structure and organization related quality indicators. However the development process of such a data framework is challenging, even in period of increasing and improving health data storage and management. This study aims to develop an integrated multi-level data framework for quality of diabetes care and to operationalize this framework in the fragmented Belgium health care and data landscape.

Methods

Based on document reviews, iterative working group discussions and expert consultations, theoretical approaches and quality indicators were identified and assessed. After mapping and assessing the validity of existing health information systems and available data sources through expert consultations, the theoretical framework was translated in a data framework with measurable quality indicators. The construction of the data base included sampling procedures, data-collection, and several technical and privacy-related aspects of linking and accessing Belgian datasets.

Results

To address three dimensions of quality of care, we integrated the chronic care model and cascade of care approach, addressing respectively the structure related quality indicators and the process and outcome related indicators. The corresponding data framework is based on self-collected data at the primary care practice level (using the Assessment of quality of integrated care tool), and linked health insurance data with lab data at the patient level.

Conclusion

In this study, we have described the transition of a theoretical quality of care framework to a unique multilevel database, which allows assessing the quality of diabetes care, by considering the complete care continuum (process and outcomes) as well as organizational characteristics of primary care practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08625-8.

Effectiveness-implementation trial comparing a family model of diabetes self-management education and support with a standard model

BACKGROUND

Diabetes self-management education and support (DSMES) is an effective approach for improving diabetes self-care behaviors to achieve improved glycemic management and other health outcomes. Engaging family members may improve outcomes, both for the person with diabetes (PWD) and for the family members. However, family models of DSMES have been inconsistently defined and delivered. We operationalize Family-DSMES to be generalizable and replicable, detail our protocol for a comparative effectiveness trial comparing Standard-DSMES with Family-DSMES on outcomes for PWDs and family members, and detail our mixed-methods implementation evaluation plan.

METHODS

We will examine Family-DSMES relative to Standard-DSMES using a Hybrid Type 1 effectiveness-implementation design. Participants are ≥18 years old with type 2 diabetes mellitus and hemoglobin A1c ≥7.0%, recruited from rural and urban primary care clinics that are part of an academic medical center. Each participant invites a family member. Dyads are randomly assigned to Family- or Standard-DSMES, delivered in a small-group format via telehealth. Data are collected at baseline, immediately post-intervention, and 6-, 12-, and 18-months post-intervention. Outcomes include PWDs' hemoglobin A1c (primary), other biometric, behavioral, and psychosocial outcomes (secondary), and family members' diabetes-related distress, involvement in the PWD's diabetes management, self-efficacy for providing support, and biometric outcomes (exploratory). Our mixed-methods implementation evaluation will include process data collected during the trial and stakeholder interviews guided by the Consolidated Framework for Implementation Research.

CONCLUSION

Results will fill knowledge gaps about which type of DSMES may be most effective and guide Family-DSMES implementation efforts.

REGISTRATION

The trial is pre-registered at clinicaltrials.gov (#NCT04334109).

Barriers and facilitators of providing standard of care diabetes management at primary care level in geriatric population

Background

Geriatric population is gradually increasing and is expected to grow till 20% by 2050 from the current 8.6%, and so is diabetes prevalence and other comorbidities. To improve diabetes control, better coordination of provider, patient and health system is needed. It has been found that almost half of the diabetes patients do not achieve treatment targets. So, it is essential to assess the perceived barriers as well as facilitators from patients' and physicians' perspectives. The aim of the study was assessment of needs, care, barriers and facilitators to achieve treatment goals for patients and physicians.

Materials and Methods

This observational, cross-sectional study was conducted by the Department of Geriatrics among 100 elderly diabetes patients and 50 physicians after obtaining ethical approval. All participants were interviewed based on a predefined, structured questionnaire with multiple options to grade or choose from.

Results

Polypharmacy, mobility issues and dementia were the most common geriatric issues. Hypertension (HTN), arthritis and coronary artery disease (CAD) were the commonest comorbidities. Also, 73% reported that they followed dietary advice, but only 22% accepted that they were doing exercise regularly. Moreover, 5% mentioned that they were taking alcohol, and 15% confirmed of smoking. Also, 47% of patients felt that diabetes was well controlled. Remaining 53% patients gave reasons for poor diabetes control; the most common reason was not following a proper diabetic diet plan in 42% of patients and lack of exercise as instructed was reported by 22% as the reason for their poor diabetic control. Nineteen percent of patients accepted of not measuring their blood glucose as instructed. Among urban doctors, the three most common factors were not being consistent with lifestyle interventions, followed by no regular self-monitoring of blood glucose and no regular follow-up. Top three interventions suggested were to engage or encourage the family members of patients to become involved in diabetes care, provide more convenient diabetes brochures or education materials to patients and improve multidisciplinary and multispeciality collaboration in diabetes control.

Conclusion

Diabetes in elderly needs proactive health system and coordinated care. Doctor-patient relationship with good communication skills, family support and multidisciplinary care is needed to improve diabetes care. Health education with a focus on diet control, exercise and other lifestyle modifications are essential factors in improving diabetes care.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Challenges in detecting and managing mild cognitive impairment in primary care: a focus group study in Shanghai, China

INTRODUCTION

Detection of mild cognitive impairment (MCI) is essential in slowing progression to dementia. Primary care plays a vital role in detecting and managing MCI. The chronic care model (CCM) provides effective methods to manage chronic diseases.

OBJECTIVE

This study aimed to explore how MCI services are delivered in primary care in China.

METHODS

Focus group interviews were conducted face to face among MCI stakeholders from six community health centres (CHCs) involved in the 'friendly community programme' in Shanghai, China. A total of 124 MCI stakeholders were interviewed, consisting of 6 groups (n=42) of general practitioners (GPs), 3 groups (n=18) of CHC managers, 4 groups (n=32) of people with MCI and 4 groups (n=32) of informal caregivers. Content and thematic analyses were performed using a combination of induction and deduction approaches.

RESULTS

Three major themes emerged from the data corresponding to the CCM framework: hesitant patients, unprepared providers and misaligned environments. While the public are hesitant to seek medical attention for MCI problems, due to misunderstanding, social stigma and a lack of perceived benefits, GPs and CHCs are not well prepared either, due to lack of knowledge and a shortage of GPs, and a lack of policy, funding and information support. None of these issues can be addressed separately without tackling the others.

CONCLUSION

This study combined the diverse perceptions of all the main stakeholders to detect and manage MCI in primary care settings in China. A vicious circle was found among the three interconnected CCM domains, creating a gridlock that should be addressed through a system's approach targeting all of the above-mentioned aspects.

Resultados preliminares de la Iniciativa HEARTS en México: facilitadores y barreras de los sistemas de información

Objetivo.

Comparar la diferencia en la cobertura y proporción de pacientes controlados con hipertensión arterial sistémica entre diciembre de 2020 y diciembre de 2021 en los establecimientos de salud con implementación de la Iniciativa HEARTS, y explorar los facilitadores y las barreras relacionados con los sistemas de información en México.

Métodos.

Estudio observacional ecológico descriptivo. Se compararon los resultados de los establecimientos de salud que han iniciado la implementación de la Iniciativa HEARTS (n=29) en Chiapas y Sonora, respecto a las variables de cobertura de atención y control de la hipertensión, en 4 periodos (semestres) del 2020 al 2021.

Resultados.

Existe mayor número de mujeres en tratamiento y en control respecto de los hombres en los diferentes grupos de edad. Se identificaron algunas barreras (p. ej.multiplicidad de sistemas, falta de interoperabilidad, conectividad limitada a internet en los establecimientos de salud) y facilitadores (p. ej.acceso libre a la información, disponibilidad de datos desde años previos, generación de estimaciones y proyecciones) en los sistemas de información.

Conclusiones.

El 55% de los establecimientos bajo implementación (16 establecimientos) mejoraron la proporción de pacientes controlados en el periodo analizado. Es importante monitorear indicadores a nivel de procesos, lo cual debe ir acompañado de una redistribución de las funciones de los equipos de salud y asegurar el abastecimiento de medicamentos para potenciar la efectividad de la estrategia. Se sugiere fortalecer la implementación con los impulsores clave para el control de la hipertensión.