Process quality, diagnosis quality, and patient satisfaction of primary care in Rural Western China: A study using standardized patients

OBJECTIVES

Patient satisfaction is an essential indicator of the doctor-patient relationship. This study aimed to investigate the relationship between primary care quality and patient satisfaction for non-communicable diseases (NCDs) in rural western China.

METHODS

The study utilized the standardized patients (SPs) approach to present typical symptoms of unstable angina and diabetes to rural healthcare providers. After the consultations, the SPs completed a satisfaction survey. Ordinary least squares and quantile regression were used to examine the association between quality of primary care and patient satisfaction.

RESULTS

We examined 178 anonymous SPs visits. The results showed that higher process quality for angina SPs was correlated with stronger satisfaction for provider ability at a low quantile of ability satisfaction. For diabetes SPs, higher process quality increased overall satisfaction at a low quantile of overall satisfaction, whereas a correct diagnosis significantly contributed to communication satisfaction at a high quantile of communication satisfaction.

CONCLUSIONS

The study found positive associations between process and diagnosis quality and SPs satisfaction. Notably, the influence of process quality was most significant among patients with lower satisfaction levels.

PRACTICE IMPLICATIONS

Provider's process quality could be a key area of improving the satisfaction levels, especially for patients with lower levels of satisfaction.

Does size matter? Hospital volume and resource use in paediatric diabetes care

AIMS

Paediatric diabetes care has become increasingly specialised due to the multidisciplinary approach and technological developments. Guidelines recommend sufficient experience of treatment teams. This study evaluates associations between hospital volume and resource use and hospital expenditure in Dutch children with diabetes.

METHODS

Retrospective cohort study using hospital claims data of 5082 children treated across 44 Dutch hospitals (2019-2020). Hospitals were categorised into three categories; small (≥20-100 patients), medium (≥100-200 patients) and large (≥200 patients). All-cause hospitalisations, consultations, technology and hospital expenditure were analysed and adjusted for age, sex, socio-economic status (SES) and hospital of treatment.

RESULTS

Fewer hospitalisations were observed in large hospitals compared to small hospitals (OR 0.48; [95% CI 0.32-0.72]; p < 0.001). Median number of yearly paediatrician visits was 7 in large and 6 in small hospitals, the significance of which was attenuated in multilevel analysis (OR ≥7 consultations: 1.89; [95%CI 0.74-4.83]; p = 0.18). Technology use varies between individual hospitals, whereas pump usage and real-time continuous glucose monitoring showed no significant differences between hospital volumes. Mean overall expenditure was highest in medium-sized centres with €6434 per patient (IQR €2555-7955); the difference in diabetes care costs was not significant between hospital patient volumes.

CONCLUSIONS

Care provision patterns vary by hospital patient volume. Large hospitals had the lowest hospitalisation rates. The use of diabetes technology was not different between hospital patient volumes. Medium-sized hospitals showed the highest overall expenditure, but diabetes care costs were similar across hospital volumes.

Silencing of forkhead box protein O-1 (FOXO-1) enhances insulin-producing cell generation from adipose mesenchymal stem cells for diabetes therapy

AIMS

Generation of mature β-cells from MSCs has been a challenge in the field of stem cell therapy of diabetes. Adipose tissue-derived mesenchymal stem cells (Ad-MSCs) have made their mark in regenerative medicine, and provide several advantages compared to other MSCs sources. Forkhead box protein O-1 (FOXO-1) is an important transcription factor for normal development of β-cells, yet its over expression in β-cells may cause glucose intolerance. In this study, we isolated, characterized Ad-MSCs from rat epididymal fat pads, differentiated these MSCs into insulin producing cells (IPCs) and studied the role of FOXO-1 in such differentiation.

MATERIALS AND METHODS

We examined the expression of FOXO-1 and its nuclear cytoplasmic localization in the generated IPCs. Afterwards we knocked down FOXO-1 using siRNA targeting FOXO-1 (siFOXO-1). The differentiated siFOXO-1 IPCs were compared to non-targeting siRNA (siNT) IPCs regarding expression of β-cell markers by qRT-PCR and western blotting, dithizone (DTZ) staining and glucose stimulated insulin secretion (GSIS).

KEY FINDINGS

Isolated Ad-MSCs exhibited all characteristics of MSCs and can generate IPCs. FOXO-1 was initially elevated during differentiation followed by a decline towards end of differentiation. FOXO-1 was dephosphorylated and localized to the nucleus upon differentiation into IPCs. Knock down of FOXO-1 improved the expression of β-cell markers in final differentiated IPCs, improved DTZ uptake and showed increased insulin secretion upon challenging with increased glucose concentration.

SIGNIFICANCE

These results portray FOXO-1 as a hindering factor of generation of IPCs whose down-regulation can generate more mature IPCs for MSCs therapy of diabetes mellitus.

The unique multidisciplinarity of diabetes-related foot disease

Few diseases globally require treatment from so many different disciplines as diabetes-related foot disease. At least 25 different professionals may be involved: casting technicians, dermatologists, diabetes (educator) nurses, diabetologists, dieticians, endocrinologists, general practitioners, human movement scientists, infectious diseases experts, microbiologists, nuclear medicine physicians, orthopaedic surgeons, orthotists, pedorthists, physical therapists, plastic surgeons, podiatric surgeons, podiatrists, prosthetists, psychologists, radiologists, social workers, tissue viability physicians, vascular surgeons, and wound care nurses. A shared vocabulary and shared treatment goals and recommendations are then essential. The International Working Group on the Diabetic Foot (IWGDF) has produced guidelines and supporting documents to stimulate and support shared and multidisciplinary evidence-based treatment in diabetes-related foot disease. In this special virtual issue of Diabetes/Metabolism Research and Reviews, all 21 documents of the 2023 update of the IWGDF Guidelines are bundled, added with a further 6 reviews from multidisciplinary experts to drive future research and clinical innovations, based on their contributions to the International Symposium on the Diabetic Foot. We hope the readers will enjoy this special virtual issue, and widely implement the knowledge shared here in their daily clinical practice and research endeavours with the goal to improve the care for people with diabetes-related foot disease.

Ontology-based decision support systems for diabetes nutrition therapy: A systematic literature review

Diabetes is a non-communicable disease that has reached epidemic proportions, affecting 537 million people globally. Artificial Intelligence can support patients or clinicians in diabetes nutrition therapy - the first medical therapy in most cases of Type 1 and Type 2 diabetes. In particular, ontology-based recommender and decision support systems can deliver a computable representation of experts' knowledge, thus delivering patient-tailored nutritional recommendations or supporting clinical personnel in identifying the most suitable diet. This work proposes a systematic literature review of the domain ontologies describing diabetes in such systems, identifying their underlying conceptualizations, the users targeted by the systems, the type(s) of diabetes tackled, and the nutritional recommendations provided. This review also delves into the structure of the domain ontologies, highlighting several aspects that may hinder (or foster) their adoption in recommender and decision support systems for diabetes nutrition therapy. The results of this review process allow to underline how recommendations are formulated and the role of clinical experts in developing domain ontologies, outlining the research trends characterizing this research area. The results also allow for identifying research directions that can foster a preeminent role for clinical experts and clinical guidelines in a cooperative effort to make ontologies more interoperable - thus enabling them to play a significant role in the decision-making processes about diabetes nutrition therapy.

Roles and competencies of the clinical psychologist in adult diabetes care-A consensus report

AIMS

Psychological care is recognised as an integral part of quality diabetes care. We set out to describe the roles and competencies of the clinical psychologist as a member of the multidisciplinary adult diabetes care team, focused on secondary care.

METHODS

The authors are clinically experienced psychologists involved in adult diabetes care, from Australia, Europe and North America, and active members of the international psychosocial aspects of diabetes study group. Consensus was reached as a group on the roles and competencies of the clinical psychologist working in adult diabetes secondary care, building both on expert opinion and a selective review and discussion of the literature on psychological care in diabetes, clinical guidelines and competency frameworks.

RESULTS

The clinical psychologist fulfils multiple roles: (1) as a clinician (psychological assessment and therapy), (2) as advisor to the healthcare team (training, consulting), (3) as a communicator and promotor of person-centred care initiatives and (4) as a researcher. Four competencies that are key to successfully fulfilling the above-mentioned roles in a diabetes setting are as follows: (a) specialised knowledge, (b) teamwork and advice, (c) assessment, (d) psychotherapy (referred to as STAP framework).

CONCLUSIONS

The roles and competencies of clinical psychologists working in diabetes extend beyond the requirements of most university and post-graduate curricula. There is a need for a comprehensive, accredited specialist post-graduate training for clinical psychologists working in diabetes care, building on the proposed STAP framework. This calls for a collaborative effort involving diabetes organisations, clinical psychology societies and diabetes psychology interest groups.

Skin-adhesive and self-healing diagnostic wound dressings for diabetic wound healing recording and electrophysiological signal monitoring

Performing efficient wound management is essential for infected diabetic wounds due to the complex pathology. Flexible electronics have been recognized as one of the promising solutions for wound management. Herein, a kind of skin-adhesive and self-healing flexible bioelectronic was developed, which could be employed as a diagnostic wound dressing to record diabetic wound healing and monitor electrophysiological signals of the patients. The flexible substrate of diagnostic wound dressings showed excellent tissue adhesive (to various substrates including biological samples), self-healing (fracture strength restores by 96%), and intrinsic antibacterial properties (antibacterial ratio >96% against multidrug-resistant bacteria). The diagnostic wound dressings could record the glucose level (1-30 mM), pH values (4-7), and body temperature (18.8-40.0 °C) around the infected diabetic wounds. Besides, the dressings could help optimize treatment strategies based on electrophysiological signals of patients monitored in real-time. This study contributes to developing flexible bioelectronics for the diagnosis and management of diabetic wounds.

Prioritizing Patient Experiences in the Management of Diabetes and Its Complications: An Endocrine Society Position Statement

Diabetes can be an arduous journey both for people with diabetes (PWD) and their caregivers. While the journey of every person with diabetes is unique, common themes emerge in managing this disease. To date, the experiences of PWD have not been fully considered to successfully implement the recommended standards of diabetes care in practice. It is critical for health-care providers (HCPs) to recognize perspectives of PWD to achieve optimal health outcomes. Further, existing tools are available to facilitate patient-centered care but are often underused. This statement summarizes findings from multistakeholder expert roundtable discussions hosted by the Endocrine Society that aimed to identify existing gaps in the management of diabetes and its complications and to identify tools needed to empower HCPs and PWD to address their many challenges. The roundtables included delegates from professional societies, governmental organizations, patient advocacy organizations, and social enterprises committed to making life better for PWD. Each section begins with a clinical scenario that serves as a framework to achieve desired health outcomes and includes a discussion of resources for HCPs to deliver patient-centered care in clinical practice. As diabetes management evolves, achieving this goal will also require the development of new tools to help guide HCPs in supporting PWD, as well as concrete strategies for the efficient uptake of these tools in clinical practice to minimize provider burden. Importantly, coordination among various stakeholders including PWD, HCPs, caregivers, policymakers, and payers is critical at all stages of the patient journey.

The Australian Health Care Homes trial: quality of care and patient outcomes. A propensity score-matched cohort study

OBJECTIVE

To assess the impact of the Health Care Homes (HCH) primary health care initiative on quality of care and patient outcomes.

DESIGN, SETTING

Quasi-experimental, matched cohort study; analysis of general practice data extracts and linked administrative data from ten Australian primary health networks, 1 October 2017 - 30 June 2021.

PARTICIPANTS

People with chronic health conditions (practice data extracts: 9811; linked administrative data: 10 682) enrolled in the HCH 1 October 2017 - 30 June 2019; comparison groups of patients receiving usual care (1:1 propensity score-matched).

INTERVENTION

Participants were involved in shared care planning, provided enhanced access to team care, and encouraged to seek chronic condition care at the HCH practice where they were enrolled. Participating practices received bundled payments based on clinical risk tier.

MAIN OUTCOME MEASURES

Access to care, processes of care, diabetes-related outcomes, hospital service use, risk of death.

RESULTS

During the first twelve months after enrolment, the mean numbers of general practitioner encounters (rate ratio, 1.14; 95% confidence interval [CI], 1.11-1.17) and Medicare Benefits Schedule claims for allied health services (rate ratio, 1.28; 95% CI, 1.24-1.33) were higher for the HCH than the usual care group. Annual influenza vaccinations (relative risk, 1.20; 95% CI, 1.17-1.22) and measurements of blood pressure (relative risk, 1.09; 95% CI, 1.08-1.11), blood lipids (relative risk, 1.19; 95% CI, 1.16-1.21), glycated haemoglobin (relative risk, 1.06; 95% CI, 1.03-1.08), and kidney function (relative risk, 1.13; 95% CI, 1.11-1.15) were more likely in the HCH than the usual care group during the twelve months after enrolment. Similar rate ratios and relative risks applied in the second year. The numbers of emergency department presentations (rate ratio, 1.09; 95% CI, 1.02-1.18) and emergency admissions (rate ratio, 1.13; 95% CI, 1.04-1.22) were higher for the HCH group during the first year; other differences in hospital use were not statistically significant. Differences in glycaemic and blood pressure control in people with diabetes in the second year were not statistically significant. By 30 June 2021, 689 people in the HCH group (6.5%) and 646 in the usual care group (6.1%) had died (hazard ratio, 1.07; 95% CI, 0.96-1.20).

CONCLUSIONS

The HCH program was associated with greater access to care and improved processes of care for people with chronic diseases, but not changes in diabetes-related outcomes, most measures of hospital use, or risk of death.

Can family doctor system improve health service utilization for patients with hypertension and diabetes in China? A difference-in-differences study

BACKGROUND

Family doctors, serving as gatekeepers, are the core of primary health care to meet basic health needs, provide accessible care, and improve attainable health. The study objective was to evaluate the impact of the family doctor system on health service utilization among patients with hypertension and diabetes in China.

METHODS

Difference-in-Differences (DID) models are constructed to estimate the net effect of the family doctor system, based on the official health management records and medical insurance claim data of patients with hypertension and diabetes in an eastern city of China.

RESULTS

The family doctor system significantly increases follow-up visits (hypertension patients coef. = 0.13, diabetes patients coef. = 0.08, both p < 0.001) and outpatient visits (hypertension patients coef. = 0.08, diabetes patients coef. = 0.05, both p < 0.001) among the contracted compared to the non-contracted. The proportion of outpatient visits in community health centers among the contracted significantly rose (hypertension patients coef. = 0.02, diabetes patients coef. = 0.04, both p < 0.001) due to significantly more outpatient visits in community health centers and fewer in secondary and tertiary hospitals. It also significantly mitigates the increase in inpatient admissions among hypertension patients but not among diabetes patients.

CONCLUSIONS

The examined family doctor system strengthens primary care, both by increasing follow-up visits and outpatient visits and promoting a rationalized structure of outpatient utilization in China.

[Assisting diabetics in Portugal: the structuring role of the Association to Protect Poor Diabetics, 1926-1946]

Assistance to diabetics in Portugal was quintessentially linked to the 1926 foundation of the Association to Protect Poor Diabetics (Associação Protetora dos Diabéticos Pobres) which was decisive in structuring diabetology in Portugal. This article shows how during the first half of the twentieth century, this association helped create a model of assistance for diabetics in this country based on the principles of modern diabetology. First, we examine its functional and clinical organization to comply with assistance policy during the New State period in Portugal. Next, we depict the organization of the assistance model, which included treatment and education of poor patients with diabetes.

Management of Outpatients With Diabetes at High Risk of Hypoglycemia

This JAMA Clinical Guidelines Synopsis summarizes the Endocrine Society’s 2023 recommendations on management of outpatients with diabetes and high risk of hypoglycemia.

Diabetes Management in Detention Facilities: A Statement of the American Diabetes Association

This statement provides guidance for diabetes care in detention facilities. It focuses on areas where the processes for delivery of care to people with diabetes in detention facilities may differ from those in the community, and key points are made at the end of each section. Areas of emphasis, which inform multiple aspects discussed in this statement, include 1) timely identification or diagnosis of diabetes treatment needs and continuity of care (at reception/intake, during transfers, and upon discharge), 2) nutrition and physical activity, 3) timely access to diabetes management tools (insulin, blood glucose monitoring, tracking data, current diabetes management technologies, etc.), and 4) treatment of the whole person with diabetes (self-management education, mental health support, monitoring and addressing long-term complications, specialty care, etc.).

Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial

BACKGROUND

Although evidence-based treatments for depression in low-resource settings are established, implementation strategies to scale up these treatments remain poorly defined. We aimed to compare two implementation strategies in achieving high-quality integration of depression care into chronic medical care and improving mental health outcomes in patients with hypertension and diabetes.

METHODS

We conducted a parallel, cluster-randomised, controlled, implementation trial in ten health facilities across Malawi. Facilities were randomised (1:1) by covariate-constrained randomisation to either an internal champion alone (ie, basic strategy group) or an internal champion plus external supervision with audit and feedback (ie, enhanced strategy group). Champions integrated a three-element, evidence-based intervention into clinical care: universal depression screening; peer-delivered psychosocial counselling; and algorithm-guided, non-specialist antidepressant management. External supervision involved structured facility visits by Ministry officials and clinical experts to assess quality of care and provide supportive feedback approximately every 4 months. Eligible participants were adults (aged 18-65 years) seeking hypertension and diabetes care with signs of depression (Patient Health Questionnaire-9 score ≥5). Primary implementation outcomes were depression screening fidelity, treatment initiation fidelity, and follow-up treatment fidelity over the first 3 months of treatment, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03711786, and is complete.

FINDINGS

Five (50%) facilities were randomised to the basic strategy and five (50%) to the enhanced strategy. Between Oct 1, 2019, and Nov 30, 2021, in the basic group, 587 patients were assessed for eligibility, of whom 301 were enrolled; in the enhanced group, 539 patients were assessed, of whom 288 were enrolled. All clinics integrated the evidence-based intervention and were included in the analyses. Of 60 774 screening-eligible visits, screening fidelity was moderate (58% in the enhanced group vs 53% in the basic group; probability difference 5% [95% CI -38% to 47%]; p=0·84) and treatment initiation fidelity was high (99% vs 98%; 0% [-3% to 3%]; p=0·89) in both groups. However, treatment follow-up fidelity was substantially higher in the enhanced group than in the basic group (82% vs 20%; 62% [36% to 89%]; p=0·0020). Depression remission was higher in the enhanced group than in the basic group (55% vs 36%; 19% [3% to 34%]; p=0·045). Serious adverse events were nine deaths (five in the basic group and four in the enhanced group) and 26 hospitalisations (20 in the basic group and six in the enhanced group); none were treatment-related.

INTERPRETATION

The enhanced implementation strategy led to an increase in fidelity in providers' follow-up treatment actions and in rates of depression remission, consistent with the literature that follow-up decisions are crucial to improving depression outcomes in integrated care models. These findings suggest that external supervision combined with an internal champion could offer an important advance in integrating depression treatment into general medical care in low-resource settings.

FUNDING

The National Institute of Mental Health.

Enhancing Diabetes Self-management and Education: A Critical Analysis of ChatGPT's Role

ChatGPT, an advanced natural language processing model, holds significant promise in diabetes self-management and education. ChatGPT excels in providing personalized educational experiences by tailoring information to meet individual patient needs and preferences. It aids patients in developing self-management skills and strategies, fostering proactive disease management. Additionally, ChatGPT addresses healthcare access disparities by enabling patients to access educational resources irrespective of their geographic location or physical limitations. However, it is important to acknowledge and address the deficiencies of ChatGPT, such as its limited medical expertise, contextual understanding, and emotional support capabilities. Strategies for optimizing ChatGPT include regular training and updating, integration of healthcare professionals' expertise, improvement in contextual comprehension, and enhancing emotional support. By addressing these limitations and striking a balance between the benefits and limitations, ChatGPT can play a significant role in empowering patients to better understand and manage diabetes. Further research and development are needed to refine ChatGPT's capabilities and address ethical considerations, but its integration in patient education holds the potential to transform healthcare delivery and create a more informed and engaged patient population.

Advances in stem cells treatment of diabetic wounds: A bibliometric analysis via CiteSpace

Diabetes is a chronic medical condition that may induce complications such as poor wound healing. Stem cell therapies have shown promise in treating diabetic wounds with pre-clinical and clinical studies. However, little bibliometric analysis has been carried out on stem cells in the treatment of diabetic wounds. In this study, we retrieved relevant papers published from January 1, 2003, to December 31, 2023, from Chinese and English databases. CiteSpace software was used to analyze the authors, institutions, and keywords by standard bibliometric indicators. Our analysis findings indicated that publications on stem cells in the treatment of diabetic wounds kept increasing. The most prolific author was Qian Cai (n = 7) and Mohammad Bayat (n = 16) in Chinese and English databases, respectively. Institutions distribution analysis showed that Chinese institutions conducted most publications, and the most prolific institution was the Chinese People's Liberation Army General Hospital (n = 9) and Shahid Beheshti University of Medical Sciences (n = 17) in Chinese and English databases, respectively. The highest centrality keyword in Chinese and English databases was "wound healing" (0.54) and "in vitro" (0.13), respectively. There were 8 and 11 efficient and convincing keyword clusters produced by a log-likelihood ratio in the Chinese and English databases, respectively. The strongest burst keyword was "exosome" (strength 3.57) and "endothelial progenitor cells" (strength 7.87) in the Chinese and English databases, respectively. These findings indicated a direction for future therapies and research on stem cells in the treatment of diabetic wounds.

Developing and exploring the validity of a patient reported experience measure for adult inpatient diabetes care

AIM

To develop and explore the validity of a Patient Reported Experience Measure (PREM) for adult inpatient diabetes care.

METHOD

27 in-depth interviews were conducted to inform the development of the 42-item PREM which was cognitively tested with 10 people. A refined 38-item PREM was piloted with 228 respondents completing a paper (n = 198) or online (n = 30) version. The performance of the PREM was evaluated by exploring (i) uptake/number of responses and (ii) survey validity by investigating whether the PREM data were of adequate quality and delivered useful information.

RESULTS

The PREM had low drop-out or missing data rates suggesting it was appropriately constructed. Analysis of item frequencies and variances, and problem score calculations concluded that questions provided sufficient score differentiation.

CONCLUSIONS

This new PREM allows for experiences of inpatient diabetes care to be measured, understood and reported on to help identify priority areas for improving care quality.

Redesigning Diabetes Care for Treatment Inertia: A Population Health Model

In the past 2 decades, health care has witnessed technological and pharmacological advancements leading to innovations in diabetes management. Despite these advances, published guidelines, and treatment algorithms, most people with diabetes remain above glycemic targets. Thus, the authors designed a novel care model aimed at improving several causative factors, including therapeutic inertia, limited access to endocrinology and cardiovascular specialists, time constraints, and complexity in incorporating clinical practice guidelines. The model involves collaboration between the diabetes specialty team and primary care providers (PCPs). The intervention reviewed uncontrolled diabetes data and the patient's electronic medical record (EMR) and sent personalized, evidence-based recommendations to the provider using the task function in the EMR. Other services (eg, diabetes education) were utilized to optimize patient care to achieve optimal glycemic targets and address cardiometabolic risk. The overall mean hemoglobin A1c (HbA1c) decreased pre-post intervention by almost 1%, and 52.1% (347 of 666) of the cohort had ≥-0.5% change in HbA1c post-intervention. All pathways exhibited a decrease in HbA1c. Team-based approaches to managing diabetes patient care were the most effective. The interventions effectively utilized the resources across the health system without placing additional load or burden on primary care or diabetes specialty care teams. In the future, the authors hope to address the limitations of the current gap caused by increasing diabetes numbers, decreasing availability of PCPs and endocrinologists, and fee-for-service models using the innovative specialty consultant-primary care connection and knowledge exchange offered by this novel model, which can only be sustained with payer's support.

Queensland Inpatient Diabetes Survey (QuIDS): patient experience survey evaluation

BACKGROUND

Measurement of inpatient experience can allow for treatment tailored to patient preferences and needs. The patient experience of diabetes care has not been explored in Queensland hospitals.

AIMS

To investigate the experiences of patients with diabetes when hospitalised using the Queensland Inpatient Diabetes Survey (QuIDS).

METHODS

In 2019 and 2021, patient experience surveys were collected as part of the statewide QuIDS, a cross-sectional study assessing the quality of inpatient care received by people with diabetes in Queensland, Australia. Patient responses were categorised and frequencies reported as percentages. Free text comments were analysed using thematic analysis methods. Pooled descriptive data were presented.

RESULTS

Responses were collected from 27 hospitals in 2019 (n = 526, 52.4% of all patients with diabetes) and 35 hospitals in 2021 (n = 709, 55.5%). Overall, patients were satisfied with their inpatient diabetes care. Areas for improvement identified by surveyed patients include the choice and timing of meals, staff knowledge about diabetes and increased diabetes self-management. Access to a specialist diabetes team was also identified as being potentially underutilised. Patient comments fell into four major themes: communication, food choices, patient autonomy and education.

CONCLUSION

Many patients reported positive inpatient experiences; however, patients also expressed dissatisfaction with their inpatient diabetes care. Our data provide unique insight and an opportunity to improve standards of care and service provision for inpatients with diabetes.

Interventions for Pancreatitis-New Approaches, Knowledge Gaps, and Research Opportunities: Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop

ABSTRACT

There exists no cure for acute, recurrent acute or chronic pancreatitis and treatments to date have been focused on managing symptoms. A recent workshop held by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) focused on interventions that might disrupt or perhaps even reverse the natural course of this heterogenous disease, aiming to identify knowledge gaps and research opportunities that might inform future funding initiatives for NIDDK. The breadth and variety of identified active or planned clinical trials traverses the spectrum of the disease and was conceptually grouped for the workshop into behavioral, nutritional, pharmacologic and biologic, and mechanical interventions. Cognitive and other behavioral therapies are proven interventions for pain and addiction, but barriers exist to their use. Whilst a disease specific instrument quantifying pain is now validated, an equivalent is lacking for nutrition - and both face challenges in ease and frequency of administration. Multiple pharmacologic agents hold promise. Ongoing development of Patient Reported Outcome (PRO) measurements can satisfy Investigative New Drug (IND) regulatory assessments. Despite multiple randomized clinical trials demonstrating benefit, great uncertainty remains regarding patient selection, timing of intervention, and type of mechanical intervention (endoscopic versus surgery). Challenges and opportunities to establish beneficial interventions for patients were identified.

Rural-urban disparities in the diagnosis and treatment of hypertension and diabetes among aging Indians

INTRODUCTION

Hypertension and diabetes are modifiable risk factors for dementia. We aimed to assess rural-urban disparities in the diagnosis and treatment of these conditions among aging Indians.

METHODS

Participants (n = 6316) were from two parallel, prospective aging cohorts in rural and urban India. Using self-report and clinical/biochemical assessments, we subdivided participants with diabetes and hypertension into undiagnosed and untreated groups. Logistic regression and Fairlie decomposition analysis were the statistical methods utilized.

RESULTS

There was a significant rural-urban disparity in undiagnosed hypertension (25.14%), untreated hypertension (11.75%), undiagnosed diabetes (16.94%), and untreated diabetes (11.62%). Further, sociodemographic and lifestyle factors, such as age and tobacco use were the common contributors to the disparities in both undiagnosed hypertension and undiagnosed diabetes, whereas education and body mass index (BMI) were significant contributors to the disparity in untreated hypertension.

DISCUSSION

Rural Indians face significant healthcare disadvantages as compared to their urban counterparts, which prompts the urgent need for strategies for equitable healthcare.

Co-creation process of an intervention to implement a multiparameter point-of-care testing device in a primary healthcare setting for non-communicable diseases in Peru

BACKGROUND

Point-of-care testing (POCT) devices are diagnostic tools that can provide quick and accurate results within minutes, making them suitable for diagnosing non-communicable diseases (NCDs). However, these devices are not widely implemented in healthcare systems and for this reason is relevant to understand the implementation process.

AIM

To describe the process and define a strategy to implement a multiparameter POCT device for diagnosing and managing NCDs in one region of Peru.

METHODS

A descriptive and non-experimental study, using the participatory methodologies of co-creation process. It was conducted in one region of Peru (Tumbes) to design an intervention for implementing a multiparameter POCT device. Two co-creation sessions were conducted involving five groups: community members, primary healthcare workers, these groups in both rural and urban settings, and regional decision-makers. These sessions included activities to understand patient journeys in receiving care for NCDs, identify facilitators and barriers to POCT devices usage, and define an implementation strategy for POCT devices in both rural and urban settings of Tumbes. The research team analysed the data and summarized key topics for discussion after each session.

RESULTS

A total of 78 participants were enrolled across the five groups. Among community members: 22.2% had only diabetes, 24.1% had only hypertension, and 18.5% had both diagnoses. In the patient journey, community members mentioned that it took at least three days to receive a diagnosis and treatment for an NCD. Most of the participants agreed that the POCT devices would be beneficial for their communities, but they also identified some concerns. The strategy for POCT devices implementation included healthcare workers training, POCT devices must be placed in the laboratory area and must be able to perform tests for glucose, glycated haemoglobin, cholesterol, and creatinine. Advertising about POCT devices should be displayed at the healthcare centres and the municipality using billboards and flyers.

CONCLUSIONS

The co-creation process was useful to develop strategies for the implementation of multiparameter POCT devices for NCDs, involving the participation of different groups of stakeholders guided by moderators in both, rural and urban, settings in Peru.

Human resources challenges in the management of diabetes and hypertension in Mozambique

BACKGROUND

The major burden of non-communicable diseases (NCDs) globally occurs in low-and middle-income countries, where this trend is expected to increase dramatically over the coming years. The resultant change in demand for health care will imply significant adaptation in how NCD services are provided. This study aimed to explore self-reported training and competencies of healthcare providers, and the barriers they face in NCD services provision.

METHODS

A qualitative design was used to conduct this study. Data was collected through semi-structured interviews with government officials within the Mozambican Ministry of Health, district health authorities, health facility managers, and health providers at urban and rural health facilities of Maputo, in Mozambique. The data was then analyzed under three domains: provider´s capacity building, health system structuring, and policy.

RESULTS

A total of 24 interviews of the 26 planed with managers and healthcare providers at national, district, and health facility levels were completed. The domains analyzed enabled the identification and description of three themes. First, the majority of health training courses in Mozambique are oriented towards infectious diseases. Therefore, healthcare workers perceive that they need to consolidate and broaden their NCD-related knowledge or else have access to NCD-related in-service training to improve their capacity to manage patients with NCDs. Second, poor availability of diagnostic equipment, tools, supplies, and related medicines were identified as barriers to appropriate NCD care and management. Finally, insufficient NCD financing reflects the low level of prioritization felt by managers and healthcare providers.

CONCLUSION

There is a gap in human, financial, and material resources to respond to the country's health needs, which is more significant for NCDs as they currently compete against major infectious disease programming, which is better funded by external partners. Healthcare workers at the primary health care level of Mozambique's health system are inadequately skilled to provide NCD care and they lack the diagnostic equipment and tools to adequately provide such care. Any increase in global and national responses to the NCD challenge must include investments in human resources and appropriate equipment.

Knowledge, attitude, and practice toward weight management among diabetic patients in Qidong City, Jiangsu Province

BACKGROUND

Weight management is an effective prevention and treatment strategy for diabetes mellitus. This study aimed to assess the knowledge, attitude, and practice (KAP) of diabetic patients towards weight management.

METHODS

Diabetic patients treated at Qidong City, Jiangsu Province, between January 2023 and June 2023 were included in this cross-sectional study. A self-designed questionnaire was used to collect their demographic characteristics and KAP toward weight management. Structural equation modeling (SEM) was employed to examine the inter-relationships among KAP scores.

RESULTS

Among a total of 503 valid questionnaires that were collected, 55.07% were filled out by men and 54.67% by those aged < 60 years. The mean scores for knowledge, attitude, and practice were 8.03 ± 3.525 (possible range: 0-13), 31.88 ± 3.524 (possible range: 10-50), and 22.24 ± 3.318 (possible range: 9-45), respectively. Pearson's correlation analysis revealed the knowledge was positively associated with attitude (r = 0.295, P < 0.001) and practice (r = 0.131, P < 0.001), and attitude was positively associated with practice (r = 0.140, P = 0.002). SEM demonstrated positive associations between knowledge and attitude (β = 0.28, P < 0.001), and attitude and practice (β = 0.09, P = 0.019). Moreover, older age was negatively associated with knowledge (β=-0.04, P = 0.001), while higher education (β = 1.220, P < 0.001), increased monthly income (β = 0.779, P < 0.001), diagnosis of fatty liver (β = 1.03, P = 0.002), and screening for excess visceral fat (β = 1.11, P = 0.002) were positively associated with knowledge.

CONCLUSION

Diabetic patients showed moderate knowledge, neutral attitudes, and inappropriate practices toward weight management. Knowledge was positively associated with attitude and practice. These findings provided valuable directions for healthcare interventions targeting improved KAP status of weight management among diabetic patients.

Wait Times for Scheduling Appointments for Prevention of Macrovascular and Microvascular Complications of Diabetes: Cross-Sectional Descriptive Study

BACKGROUND

Diabetes is a chronic disease that requires lifelong management and care, affecting around 422 million people worldwide and roughly 37 million in the United States. Patients newly diagnosed with diabetes must work with health care providers to formulate a management plan, including lifestyle modifications and regular office visits, to improve metabolic control, prevent or delay complications, optimize quality of life, and promote well-being.

OBJECTIVE

Our aim is to investigate one component of system-wide access to timely health care for people with diabetes in New York City (NYC), namely the length of time for someone with newly diagnosed diabetes to obtain an appointment with 3 diabetes care specialists: a cardiologist, an endocrinologist, and an ophthalmologist, respectively.

METHODS

We contacted the offices of 3 different kinds of specialists: cardiologists, endocrinologists, and ophthalmologists, by telephone, for this descriptive cross-sectional study, to determine the number of days required to schedule an appointment for a new patient with diabetes. The sampling frame included all specialists affiliated with any private or public hospital in NYC. The number of days to obtain an appointment with each specialist was documented, along with "time on hold" when attempting to schedule an appointment and the presence of online booking capabilities.

RESULTS

Of the 1639 unique physicians affiliated with (private and public) hospitals in the 3 subspecialties, 1032 (cardiologists, endocrinologists, and ophthalmologists) were in active practice and did not require a referral. The mean wait time for scheduling an appointment was 36 (SD 36.4; IQR 12-51.5) days for cardiologists; 82 (SD 47; IQR 56-101) days for endocrinologists; and 50.4 (SD 56; IQR 10-72) days for ophthalmologists. The median wait time was 27 days for cardiologists, 72 days for endocrinologists, and 30 days for ophthalmologists. The mean time on hold while attempting to schedule an appointment with these specialists was 2.6 (SD 5.5) minutes for cardiologists, 5.4 (SD 4.3) minutes for endocrinologists, and 3.2 (SD 4.8) minutes for ophthalmologists, respectively. Over 46% (158/341) of cardiologists enabled patients to schedule an appointment on the web, and over 55% (128/228) of endocrinologists enabled patients to schedule an appointment on the web. In contrast, only approximately 25% (117/463) of ophthalmologists offered web-based appointment scheduling options.

CONCLUSIONS

The results indicate considerable variation in wait times between and within the 3 specialties examined for a new patient in NYC. Given the paucity of research on wait times for newly diagnosed people with diabetes to obtain an appointment with different specialists, this study provides preliminary estimates that can serve as an initial reference. Additional research is needed to document the extent to which wait times are associated with complications and the demographic and socio-economic characteristics of people served by different providers.

The effect of hyperbaric oxygen therapy on hematological indices and biochemical parameters in patients with diabetic foot

BACKGROUND

Diabetes Mellitus (DM) is a metabolic disease with a high morbidity and mortality and increasing in prevalence all over the world. Due to the hypoxic, ischemic, inflammatory, and infective environment in DM, diabetic foot ulcers have been treated with medico-surgical interventions and adjuvant hyperbaric oxygen Therapy (HBOT). The purpose of this study was to evaluate the effects of HBOT on hematological indices and biochemical parameters in patients with diabetic foot.

METHODS

The study group was formed from the file records of 103 male patients who applied to Yunus Emre State Hospital HBOT Center between September 1, 2016 and December 31, 2020, and were treated HBOT with a multidisciplinary approach.

RESULTS

There were negative low correlations between number of HBOT sessions and Mean Corpuscular Hemoglobin (MCH) (P = .037, r = -0.207) and Blood Urea Nitrogen (BUN) (P = .037, r = -0.222). White Blood Cell Count (WBC), Neutrophils (NEU), Monocytes (MON), Platelet Count (PLT), and Plateletcrit (PTC) parameters were found to be decreased, and an increase in lymphocytes (LYM), Eosinophils (EOS), Mean Corpuscular Hemoglobin Concentration (MCHC), and Red Cell Distribution Width (RDW) parameters were detected after the treatments (P < .05). Again, after the treatment, glucose (Glu), C-Reactive Protein (CRP), direct bilirubin, and total protein (TP) levels were decreased, and uric acid (UA) levels increased (P < .05).

CONCLUSION

HBOT improved hematological indices in patients and had a beneficial effect on biochemical parameters, particularly Glu and CRP levels. Adjuvant HBOT alleviates diabetic inflammation and has a beneficial effect on diabetic patient treatment.

Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda

INTRODUCTION

Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease.

METHODS AND ANALYSIS

This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension.

ETHICS AND DISSEMINATION

The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications.

TRIAL REGISTRATION NUMBER

ISRCTN15319595.

Temporal Trends in the Initiation of Dialysis Among Patients With Heart Failure With or Without Diabetes: A Nationwide Study From 2002 to 2016

BACKGROUND

The incidence and distribution of acute and chronic dialysis among patients with heart failure (HF), stratified by diabetes, remain uncertain. We hypothesized that with improved survival and rising comorbidities, the demand for dialysis would increase over time.

METHODS AND RESULTS

Patients with incident HF, aged 18 to 100 years, between 2002 and 2016, were identified using Danish nationwide registers. Primary outcomes included acute and chronic dialysis initiation, HF-related hospitalization, and all-cause mortality. These outcomes were assessed in 2002 to 2006, 2007 to 2011, and 2012 to 2016, stratified by diabetes. We calculated incidence rates (IRs) per 1000 person-years and hazard ratios (HR) using multivariable Cox regression. Of 115 533 patients with HF, 2734 patients received acute dialysis and 1193 patients received chronic dialysis. The IR was 8.0 per 1000 and 3.5 per 1000 person-years for acute and chronic dialysis, respectively. Acute dialysis rates increased significantly among patients with diabetes over time, while no significant changes occurred in those without diabetes, chronic dialysis, HF-related hospitalization, or overall mortality. Diabetes was associated with significantly higher HRs of acute and chronic dialysis, respectively, compared with patients without diabetes (HR, 2.07 [95% CI, 1.80-2.39] and 2.93 [95% CI, 2.40-3.58] in 2002 to 2006; HR, 2.45 [95% CI, 2.14-2.80] and 2.86 [95% CI, 2.32-3.52] in 2007 to 2011; and 2.69 [95% CI, 2.33-3.10] and 3.30 [95% CI, 2.69-4.06] in 2012 to 2016).

CONCLUSIONS

The IR of acute and chronic dialysis remained low compared with HF-related hospitalizations and mortality. Acute dialysis rates increased significantly over time, contrasting no significant trends in other outcomes. Diabetes exhibited over 2-fold increased rates of the outcomes. These findings emphasize the importance of continued monitoring and renal care in patients with HF, especially with diabetes, to optimize outcomes and prevent adverse events.

Knowledge, attitude, and practice of pre-diabetic older people regarding pre-diabetes

BACKGROUND

One of the risk factors of diabetes is the pre-diabetes stage which is significantly prevalent in older people. Knowledge, attitude, and practice of the pre-diabetic stage are of great importance and can decrease complications. The present study aimed to determine the knowledge, attitude, and practice of the pre-diabetic older people.

METHODS

This cross-sectional study was conducted from April 2022 to August 2022 on 219 pre-diabetic older people referring to Sina Hospital in Tabriz, one of the most populated cities in the northwest of Iran. Data were collected using questionnaires of Knowledge, Attitude, Practice-Prediabetes Assessment Questionnaire (KAP-PAQ). The data were analyzed by SPSS 21.

RESULTS

The mean scores of knowledge (in the range of 0-17), attitude (in the range of -10, + 10), and practice (in the range of 0-26) were 1.72 ± 1.0, 2.24 ± 1.92, and 5.76 ± 2.61, respectively. The older people's knowledge and practice levels in the pre-diabetes stage were low and about 50% of them had negative views. According to the Spearman correlation test, there was a positive significant relationship between the older people's knowledge and practice (p < 0.001, r = 0.234).

CONCLUSIONS

The older people in the pre-diabetes stage had low knowledge and attitude and a negative viewpoint towards correcting lifestyle on diet, exercising and physical activity, weight control, diagnostic and screening methods. Increased knowledge about pre-diabetes and strengthened positive attitude towards correcting lifestyle through counseling as well as empowering the pre-diabetic older people can increase the efficiency of pre-diabetes prevention and control programs and prevent its progression to the diabetes stage.

Improving Diabetes Control in a Medicaid Managed Care Population With Complex Needs

INTRODUCTION

People enrolled in Medicaid managed care who struggle with diabetes control often have complex medical, behavioral, and social needs. Here the authors report the results of a program designed to partner with primary care teams to address those needs.

METHODS

A nonprofit organization partnered with a Medicaid managed care plan and a Federally Qualified Health Center in California to enroll people with A1cs >9% in a 12-month program. The program team included a community health worker, certified diabetes care and education specialist/registered dietitian, behavioral health counselor, and registered nurse. They developed patient-led action plans, connected patients to community resources, and supported behavior changes to improve diabetes control. Baseline assessments of behavioral health conditions and social needs were collected. Monthly A1c values were tracked for participants and a comparison group.

RESULTS

Of the 51 people enrolled, 83% had at least 1 behavioral health condition. More than 90% reported at least 1 unmet social need. The average monthly A1c among program participants was 0.699 lower than the comparison group post-enrollment (P = .0008), and the disparity in A1c between Hispanic and non-Hispanic White participants at enrollment declined.

DISCUSSION

Participants had high levels of unmet medical, behavioral, and social needs. Addressing these needs resulted in a rapid and sustained improvement in A1c control compared to non-enrollees and a reduction in disparity of control among Hispanic participants.

CONCLUSION

By partnering with a primary care team, a program external to Federally Qualified Health Center primary care can improve clinical outcomes for people with complex needs living with diabetes.

Internet of Things enabled open source assisted real-time blood glucose monitoring framework

Regular monitoring of blood glucose levels is essential for the management of diabetes and the development of appropriate treatment protocols. The conventional blood glucose (BG) testing have an intrusive technique to prick the finger and it can be uncomfortable when it is a regular practice. Intrusive procedures, such as fingerstick testing has negatively influencing patient adherence. Diabetic patients now have an exceptional improvement in their quality of life with the development of cutting-edge sensors and healthcare technologies. intensive care unit (ICU) and pregnant women also have facing challenges including hyperglycemia and hypoglycemia. The worldwide diabetic rate has incited to develop a wearable and accurate non-invasive blood glucose monitoring system. This research developed an Internet of Things (IoT) - enabled wearable blood glucose monitoring (iGM) system to transform diabetes care and enhance the quality of life. The TTGOT-ESP32 IoT platform with a red and near-infrared (R-NIR) spectral range for blood glucose measurement has integrated into this wearable device. The primary objective of this gadget is to provide optimal comfort for the patients while delivering a smooth monitoring experience. The iGM gadget is 98.82 % accuracy when used after 10 hours of fasting and 98.04 % accuracy after 2 hours of breakfast. The primary objective points of the research were continuous monitoring, decreased risk of infection, and improved quality of life. This research contributes to the evolving field of IoT-based healthcare solutions by streaming real-time glucose values on AWS IoT Core to empower individuals with diabetes to manage their conditions effectively. The iGM Framework has a promising future with the potential to transform diabetes management and healthcare delivery.

How have services for diabetes, eye, hearing and foot health been integrated for adults? Protocol for a scoping review

INTRODUCTION

The global population is ageing, and by 2050, there will be almost 2.1 billion people over the age of 60 years. This ageing population means conditions such as diabetes are on the increase, as well as other conditions associated with ageing (and/or diabetes), including those that cause vision impairment, hearing impairment or foot problems. The aim of this scoping review is to identify the extent of the literature describing integration of services for adults of two or more of diabetes, eye, hearing or foot services.

METHODS AND ANALYSIS

The main database searches are of Medline and Embase, conducted by an information specialist, without language restrictions, for studies published from 1 January 2000 describing the integration of services for two or more of diabetes, eye, hearing and foot health in the private or public sector and at the primary or secondary level of care, primarily targeted to adults aged ≥40 years. A grey literature search will focus on websites of key organisations. Reference lists of all included articles will be reviewed to identify further studies. Screening and data extraction will be undertaken by two reviewers independently and any discrepancies will be resolved by discussion. We will use tables, maps and text to summarise the included studies and findings, including where studies were undertaken, which services tended to be integrated, in which sector and level of the health system, targeting which population groups and whether they were considered effective.

ETHICS AND DISSEMINATION

As our review will be based on published data, ethical approval will not be sought. This review is part of a project in Aotearoa New Zealand that aims to improve access to services for adults with diabetes or eye, hearing or foot conditions. The findings will be published in a peer-reviewed journal and presented at relevant conferences.

Effectiveness of a Disease Management Program (DMP) in controlling the progression of Chronic Kidney Disease among hypertensives and diabetics

Background

The occurrence rate of stage 5 chronic kidney disease (CKD) will be 151 per million population in India in the coming years. Comorbidities like diabetes mellitus and hypertension are the usual triggers of CKD. Hence this study aimed to control the progression of CKD and to note the effectiveness of a structured education program that would help in the prevention of complications related to diabetes and hypertension.

Methods

This quasi-experimental study was conducted among 88 participants who had hypertension, diabetes mellitus, or both for five or more years. The study objective was to find the effect of a Disease Management Program on delaying progression of CKD in patients with hypertension or diabetes mellitus.The baseline data were obtained from demographic proforma, and the clinical data collected were the blood pressure, serum creatinine, and random blood sugar (RBS) of the participants. The management of hypertension and diabetes mellitus was taught to them. In the fourth and the eighth month, blood pressure and blood sugar were reassessed. At one-year blood pressure, blood sugar, and serum creatinine were tested. Baseline and one-year follow-up blood pressure, blood sugar, and estimated Glomerular Filtration Rate were compared. Descriptive statistics and "Wilcoxon signed-rank test" were used to analyze the data.

Results

In one year, the mean systolic blood pressure reduced by six mm of Hg and mean blood sugar by 24 mg/dl. The prevalence of CKD stage three and above (< 60 ml/min/m2) was nine (10.22%). The median decline in eGFR was 5 ml/min/m2 (Z= 5.925, P< 0.001).

Conclusion

The Disease Management Program led to improvements in blood pressure and diabetes control and median progression of CKD was estimated at five ml/min/m2/year.

Extended cost-effectiveness analysis of interventions to improve uptake of diabetes services in South Africa

The rising prevalence of diabetes in South Africa (SA), coupled with significant levels of unmet need for diagnosis and treatment, results in high rates of diabetes-associated complications. Income status is a determinant of utilization of diagnosis and treatment services, with transport costs and loss of wages being key barriers to care. A conditional cash transfer (CCT) programme, targeted to compensate for such costs, may improve service utilization. We applied extended cost-effectiveness analysis (ECEA) methods and used a Markov model to compare the costs, health benefits and financial risk protection (FRP) attributes of a CCT programme. A population was simulated, drawing from SA-specific data, which transitioned yearly through various health states, based on specific probabilities obtained from local data, over a 45-year time horizon. Costs and disability-adjusted life years (DALYs) were applied to each health state. Three CCT programme strategies were simulated and compared to a 'no programme' scenario: (1) covering diagnosis services only; (2) covering treatment services only; (3) covering both diagnosis and treatment services. Cost-effectiveness was reported as incremental net monetary benefit (INMB) using a cost-effectiveness threshold of USD3015 per DALY for SA, while FRP outcomes were reported as catastrophic health expenditure (CHE) cases averted. Distributions of the outcomes were reported by income quintile and sex. Covering both diagnosis and treatment services for the bottom two quintiles resulted in the greatest INMB (USD22 per person) and the greatest CHE cases averted. There were greater FRP benefits for women compared to men. A CCT programme covering diabetes diagnosis and treatment services was found to be cost-effective, when provided to the poorest 40% of the SA population. ECEA provides a useful platform for including equity considerations to inform priority setting and implementation policies in SA.

Factors influencing the technical efficiency of diabetes care at primary care level in Mexico

Diabetes prevalence is rising globally, especially in low- and middle-income countries like Mexico, posing challenges for healthcare systems that require efficient primary care to manage the disease. However, healthcare efficiency is influenced by factors beyond decision-makers, including socioeconomic and political conditions. This study aims to evaluate the technical efficiency of primary healthcare for diabetes patients in Mexico over a 12-year period and explore the impact of contextual variables on efficiency. A longitudinal analysis was conducted using administrative and socio-demographic data from 242 health jurisdictions between 2009 and 2020. Data envelopment analysis with bootstrapping and output orientation was used to measure the technical efficiency; health resources in infrastructure and human resources were used as inputs. As outcome, the number of patients receiving treatment for diabetes and the number of patients with controlled diabetes were considered. Machine learning algorithms were employed to analyse multiple factors affecting the provision of diabetes health services and assess heterogeneity and trends in efficiency across different health jurisdictions. The average technical efficiency in primary healthcare for diabetes patients was 0.44 (CI: 0.41-0.46) in 2009, reaching a peak of 0.71 (CI: 0.69-0.72) in 2016, and moderately declining to 0.60 (CI: 0.57-0.62) in 2020; these differences were statistically significant. The random forest analysis identified the marginalization index, primary healthcare coverage, proportion of indigenous population and demand for health services as the most influential variables in predicting efficiency levels. This research underscores the crucial need for the formulation of targeted public policies aimed at extending the scope of primary healthcare services, with a particular focus on addressing the unique challenges faced by marginalized and indigenous populations. According to our results, it is necessary that medical care management adjust to the specific demands and needs of these populations to guarantee equitable care in Mexico.

Gap analysis of diabetes-related foot disease management systems in Pacific Islands Countries and Territories

BACKGROUND

Pacific Island Countries and Territories (PICTs) are known to have high prevalence of Diabetes Mellitus and high incidence of diabetes-related foot disease. Diabetes-related foot disease can lead to lower limb amputation and is associated with poor outcomes, with increased morbidity and mortality. The purpose of this study was to gain a better understanding of diabetes-related foot disease management in selected countries in PICTs and to identify potential barriers in management of diabetes-related foot disease management in the region.

METHODS

A cross-sectional survey was sent to eleven hospitals across six selected PICTs. The survey instrument was designed to provide an overview of diabetes-related foot disease (number of admissions, and number of lower limb amputations over 12 months) and to identify clinical services available within each institution. Two open-ended questions (free text responses) were included in the instrument to explore initiatives that have helped to improve management and treatment of diabetes-related foot diseases, as well as obstacles that clinicians have encountered in management of diabetes-related foot disease. The survey was conducted over 6 weeks.

RESULTS

Seven hospitals across four countries provided responses. Number of admissions and amputations related to diabetes-related foot disease were only reported as an estimate by clinicians. Diabetes-related foot disease was managed primarily by general medicine physician, general surgeon and/or orthopaedic surgeon in the hospitals surveyed, as there were no subspecialty services in the region. Only one hospital had access to outpatient podiatry. Common themes identified around barriers faced in management of diabetes-related foot disease by clinicians were broadly centred around resource availability, awareness and education, and professional development.

CONCLUSION

Despite the high prevalence of diabetes-related foot disease within PICTs, there appears to be a lack of functional multi-disciplinary foot services (MDFs). To improve the outcomes for diabetes-related foot disease patients in the region, there is a need to establish functional MDFs and engage international stakeholders to provide ongoing supports in the form of education, mentoring, as well as physical resources.

Development of a patient satisfaction questionnaire (PSQ) for diabetes management in Thailand and Lao PDR

In a cross-sectional analytical study, a Patient Satisfaction Questionnaire (PSQ) for diabetes management was developed and tested in Thailand and Lao PDR. A systematic review of qualitative studies was conducted to formulate themes of the PSQ. The 20-item PSQ was prepared in Thai and translated to Lao, with subsequent backward translation. Both versions were tested for reliability and construct validity using confirmatory factor analysis and structural equation modeling. The study was performed at a university hospital in Thailand and two central hospitals in Vientiane, Lao PDR. There were 300 diabetic patients from Thailand (n = 150) and Lao PDR (n = 150). The 5-factor Thai version showed 74.52% of total explained variance with good internal consistency and satisfactory goodness-of-fit indices (χ2/df = 1.91, GFI = 0.83, CFI = 0.98, SRMR = 0.063, RMSEA = 0.078). The five factors were 1) Standard of Service, 2) Diabetic Service, 3) Competency of Providers, 4) Competency of Pharmacists, and 5) Communication with Providers. For the Lao version, 20 items showed a 3-factor structure with a total explained variance of 71.09%. Goodness-of-fit indices for the Lao model were satisfactory (χ2/df = 2.45, GFI = 0.78, CFI = 0.95, SRMR = 0.075 and RMSEA = 0.095). The results showed the PSQ Thai and Lao versions were valid and reliable for assessing patient satisfaction with diabetes management, however more testing of the questionnaire is appropriate.

Evaluation of the prevalence of cardiometabolic disorders (diabetes, hypertension, and hyperlipidemia) diagnosed, undiagnosed, treated, and treatment goal in the elderly: Bushehr Elderly Health Program (BEH)

As the population ages, the global burden of cardiometabolic disorders will increase. This study aimed to investigate the prevalence of cardiometabolic disorders (diabetes, hypertension, and hyperlipidemia) in elderly and to evaluate the effects of various variables including age, sex, education, marital status, smoking, income, physical activity, dementia and depressed mood on untreated cardiometabolic disorders. This was a cross sectional study conducted in Bushehr Elderly Health Program. A total 2381 participants were included. Medical data were collected by trained interviewers. The mean age of the study participants was 69.34 years. Proportions of diabetes, hypertension, hyperlipidemia and hypercholesterolemia were 43.25%, 75.71%, 64.74% and 35.31% respectively. Untreated diabetes prevalence was higher for males (OR = 1.60, 95%CI = 1.20-2.15), older adults (OR = 1.02, 95%CI = 1.00-1.05), and pre-frail status (OR = 0.69, 95%CI = 0.52-0.92). Males (OR = 2.16, 95%CI = 1.64-2.84) and current smokers (OR = 1.42, 95%CI = 1.05-1.93), in contrast to married participants (OR = 0.25, 95%CI = 0.08-0.78), people with higher education levels (OR = 0.51, 95%CI = 0.29-0.89) and dementia (OR = 0.78, 95%CI = 0.61-1.00) were more likely to have untreated HTN. Untreated dyslipidemia is more common in smokers (OR = 1.78, 95%CI = 1.19-2.66) and males (OR = 1.66, 95%CI = 1.21-2.27), while untreated hypercholesteremia is more common in males (OR = 3.20, 95%CI = 1.53-6.69) and is reported lower in people with dementia (OR = 0.53, 95%CI = 0.28-1.01).

Enrollment in High-Deductible Health Plans and Incident Diabetes Complications

Importance

Preventing diabetes complications requires monitoring and control of hyperglycemia and cardiovascular risk factors. Switching to high-deductible health plans (HDHPs) has been shown to hinder aspects of diabetes care; however, the association of HDHP enrollment with microvascular and macrovascular diabetes complications is unknown.

Objective

To examine the association between an employer-required switch to an HDHP and incident complications of diabetes.

Design, Setting, and Participants

This retrospective cohort study used deidentified administrative claims data for US adults with diabetes enrolled in employer-sponsored health plans between January 1, 2010, and December 31, 2019. Data analysis was performed from May 26, 2022, to January 2, 2024.

Exposures

Adults with a baseline year of non-HDHP enrollment who had to switch to an HDHP because their employer offered no non-HDHP alternative in that year were compared with adults who were continuously enrolled in a non-HDHP.

Main Outcomes and Measures

Mixed-effects logistic regression models examined the association between switching to an HDHP and, individually, the odds of myocardial infarction, stroke, hospitalization for heart failure, lower-extremity complication, end-stage kidney disease, proliferative retinopathy, treatment for retinopathy, and blindness. Models were adjusted for demographics, comorbidities, and medications, with inverse propensity score weighting used to account for potential selection bias.

Results

The study included 42 326 adults who switched to an HDHP (mean [SD] age, 52 [10] years; 19 752 [46.7%] female) and 202 729 adults who did not switch (mean [SD] age, 53 [10] years; 89 828 [44.3%] female). Those who switched to an HDHP had greater odds of experiencing all diabetes complications (odds ratio [OR], 1.11; 95% CI, 1.06-1.16 for myocardial infarction; OR, 1.15; 95% CI, 1.09-1.21 for stroke; OR, 1.35; 95% CI, 1.30-1.41 for hospitalization for heart failure; OR, 2.53; 95% CI, 2.38-2.70 for end-stage kidney disease; OR, 2.23; 95% CI, 2.17-2.29 for lower-extremity complication; OR, 1.17; 95% CI, 1.13-1.21 for proliferative retinopathy; OR, 2.35; 95% CI, 2.18-2.54 for blindness; and OR, 2.28; 95% CI, 2.15-2.41 for retinopathy treatment).

Conclusions and Relevance

This study found that an employer-driven switch to an HDHP was associated with increased odds of experiencing all diabetes complications. These findings reinforce the potential harm associated with HDHPs for people with diabetes and the importance of affordable and accessible chronic disease management, which is hindered by high out-of-pocket costs incurred by HDHPs.