The Relationship Between Financial Incentives and Quality of Diabetes Care in Ontario, Canada

PubMed Central

Kiran, Tara; Victor, J. Charles; Kopp, Alexander; Shah, Baiju R.; Glazier, Richard H.

2012-01-01

OBJECTIVE We assessed the impact of a diabetes incentive code introduced for primary care physicians in Ontario, Canada, in 2002 on quality of diabetes care at the population and patient level. RESEARCH DESIGN AND METHODS We analyzed administrative data for 757,928 Ontarians with diabetes to examine the use of the code and receipt of three evidence-based monitoring tests from 2006 to 2008. We assessed testing rates over time and before and after billing of the incentive code. RESULTS One-quarter of Ontarians with diabetes had an incentive code billed by their physician. The proportion receiving the optimal number of all three monitoring tests (HbA1c, cholesterol, and eye tests) rose gradually from 16% in 2000 to 27% in 2008. Individuals who were younger, lived in rural areas, were not enrolled in a primary care model, or had a mental illness were less likely to receive all three recommended tests. Patients with higher numbers of incentive code billings in 2006–2008 were more likely to receive recommended testing but also were more likely to have received the highest level of recommended testing prior to introduction of the incentive code. Following the same patients over time, improvement in recommended testing was no greater after billing of the first incentive code than before. CONCLUSIONS The diabetes incentive code led to minimal improvement in quality of diabetes care at the population and patient level. Our findings suggest that physicians who provide the highest quality care prior to incentives may be those most likely to claim incentive payments. PMID:22456866

Family physician ethnicity influences quality of diabetes care for Chinese but not South Asian patients.

PubMed

Shah, Baiju R; Hwee, Jeremiah; Anand, Sonia S; Austin, Peter C; Manuel, Douglas G; Hux, Janet E

2015-12-01

To determine whether sharing the same ethnicity as their family physician influenced the quality of diabetes care for Chinese and South Asian patients in Ontario, Canada. We conducted two related studies: a population-based cohort study of Chinese and South Asian patients with incident diabetes using health care administrative data (n=49,484), and a cross-sectional study of Chinese and South Asian patients with established diabetes using data collected directly from their family physicians' clinical records (n=416). In both studies, quality of care measures were compared between patients whose family physicians were or were not from the same ethnic group. In the cohort study, Chinese patients whose family physicians were also Chinese were more likely to have a diabetes-related family physician visit and appropriate HbA1c and cholesterol testing. In the cross-sectional study, they were more likely to have foot examinations, to have microalbuminuria testing, and to achieve recommended treatment targets for HbA1c and for LDL-cholesterol. In contrast, for South Asian patients, most quality measures in either study did not differ by physician ethnicity. Having a family physician from the same ethnic group was associated with better quality of diabetes care for Chinese but not for South Asian patients. Copyright © 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Measuring primary care organizational capacity for diabetes care coordination: the Diabetes Care Coordination Readiness Assessment.

PubMed

Weeks, Douglas L; Polello, Jennifer M; Hansen, Daniel T; Keeney, Benjamin J; Conrad, Douglas A

2014-01-01

Not all primary care clinics are prepared to implement care coordination services for chronic conditions, such as diabetes. Understanding true capacity to coordinate care is an important first-step toward establishing effective and efficient care coordination. Yet, we could identify no diabetes-specific instruments to systematically assess readiness and/or status of primary care clinics to engage in diabetes care coordination. This report describes the development and initial validation of the Diabetes Care Coordination Readiness Assessment (DCCRA), which is intended to measure primary care clinic readiness to coordinate care for adult patients with diabetes. The instrument was developed through iterative item generation within a framework of five domains of care coordination: Organizational Capacity, Care Coordination, Clinical Management, Quality Improvement, and Technical Infrastructure. Validation data was collected on 39 primary care clinics. Content validity, inter-rater reliability, internal consistency, and construct validity of the 49-item instrument were assessed. Inter-rater agreement indices per item ranged from 0.50 to 1.0. Cronbach's alpha of the entire instrument was 0.964, and for the five domain scales ranged from 0.688 to 0.961. Clinics with existing care coordinators were rated as more ready to support care coordination than clinics without care coordinators for the entire DCCRA and for each domain, supporting construct validity. As providers increasingly attempt to adopt patient-centered approaches, introduction of the DCCRA is timely and appropriate for assisting clinics with identifying gaps in provision of care coordination services. The DCCRA's strengths include promising psychometric properties. A valid measure of diabetes care coordination readiness should be useful in diabetes program evaluation, assistance with quality improvement initiatives, and measurement of patient-centered care in research.

Differences in the quality of diabetes care caused by social inequalities disappear after treatment and education in a tertiary care centre.

PubMed

Bäz, L; Müller, N; Beluchin, E; Kloos, C; Lehmann, T; Wolf, G; Müller, U A

2012-05-01

To assess the relationship between social status and quality of diabetes care in a tertiary care centre in Germany. Social status was assessed in 940 consecutive patients in a university outpatient department by a questionnaire. The assessment comprised three components: education, highest professional position and household net income (total score 3-21). Quality of diabetes care was measured by HbA(1c) , blood pressure and BMI. The influence of social status on quality measures was analysed at entry and last visit by fitting linear mixed models. At the entry visit, patients with lower social status had a higher HbA(1c) compared with patients with higher status (0.06% per each point of social score difference). After a mean follow- up of 6.0 years (Type 2 diabetes) and 9.4 years (Type 1 diabetes) no significant differences in HbA(1c) could be found. However, difference in BMI (-0.41 kg/m² per each point of social score) persisted at last observation. Blood pressure was only negligibly affected by the care programme. Low social status is associated with worse quality of diabetes care at entry in a tertiary care centre. The differences in HbA(1c) disappeared after treatment and structured education, whereas the difference in BMI persisted. There was no significant influence of social status or treatment on blood pressure. © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.

Provider and systems factors in diabetes quality of care.

PubMed

Ghaznavi, Kimia; Malik, Shaista

2012-02-01

A gap exists in knowledge and the observed frequency with which patients with diabetes actually receive treatment for optimal cardiovascular risk reduction. Many interventions to improve quality of care have been targeted at the health systems level and provider organizations. Changes in several domains of care and investment in quality by organizational leaders are needed to make long-lasting improvements. In the studies reviewed, the most effective strategies often have multiple components, whereas the use of one single strategy, such as reminders only or an educational intervention, is less effective. More studies are needed to examine the effect of several care management strategies simultaneously, such as use of clinical information systems, provider financial incentives, and organizational model on processes of care and outcomes.

Quality of care provided to patients with diabetes mellitus in Puerto Rico; managed care versus fee-for-service experience.

PubMed

Rodríguez-Vigil, Efraín; Kianes-Pérez, Zaira

2005-01-01

To evaluate and compare the quality of diabetes care in a large managed care system and fee-for-service payment system in Puerto Rico. This retrospective cross-sectional study assessed the adherence to standards of diabetes care in 1,687,202 subjects--226,210 from a fee-for-service population and 1,460,992 from a managed care group. Patients with diabetes mellitus were identified from insurance claims reports. Type of health-care provider, service location, number of visits, and laboratory utilization were also assessed. From the analysis, we identified 90,616 patients with diabetes (5.4% of the overall study group). Of these, 66,587 (73.5%) were found to have at least one encounter with a physician in a medical visit. Of the 66,586 patients with diabetes who visited a physician, only 4% were treated by an endocrinologist. General laboratory utilization was 34% for the entire population of patients with diabetes studied. In the group of patients with documented laboratory tests, 93% had a documented fasting blood glucose test; in contrast, hemoglobin A lc testing was performed in only 9% of the patients. The fee-for-service group had a higher rate of visits to medical specialists and general laboratory utilization, whereas the managed care group had a higher rate of hospital admissions and emergency department visits. The quality of diabetes management and the subsequent outcomes are related to patient and health-care provider adherence to standards of care. In this analysis, we found that patients and physicians are responsible for low compliance with recognized standards of diabetes care in Puerto Rico. The lack of adequate management will lead to increased mortality, development and severity of chronic complications, and increased emergency department utilization. Therefore, health-care providers and payers should find ways to achieve more effective promotion of adherence to accepted standards of care for patients with diabetes.

Sustaining quality in the community: trends in the performance of a structured diabetes care programme in primary care over 16 years.

PubMed

Riordan, F; McHugh, S M; Harkins, V; Marsden, P; Kearney, P M

2018-04-29

To examine the quality of care delivered by a structured primary care-led programme for people with Type 2 diabetes mellitus in 1999-2016. The Midland Diabetes Structured Care Programme provides structured primary care-led management. Trends over time in care processes were examined (using a chi-squared trend test and age- and gender-adjusted logistic regression). Screening and annual review attendance were reviewed. A composite of eight National Institute for Health and Care Excellence-recommended processes was used as a quality indicator. Participants who were referred to diabetes nurse specialists were compared with those not referred (Student's t-test, Pearson's chi-squared test, Wilcoxon-Mann-Whitney test). Proportions achieving outcome targets [HbA 1c ≤58 mmol/mol (7.5%), blood pressure ≤140/80 mmHg, cholesterol <5.0 mmol/l] were calculated. Data were available for people with diabetes aged ≥18 years: 1998/1999 (n=336); 2003 (n=843); 2008 (n=988); and 2016 (n=1029). Recording of some processes improved significantly over time (HbA 1c , cholesterol, blood pressure, creatinine), and in 2016 exceeded 97%. Foot assessment and annual review attendance declined. In 2016, only 29% of participants had all eight National Institute for Health and Care Excellence processes recorded. A higher proportion of people with diabetes who were referred to a diabetes nurse specialist had poor glycaemic control compared with those not referred. The proportions meeting blood pressure and lipid targets increased over time. Structured primary care led to improvements in the quality of care over time. Poorer recording of some processes, a decline in annual review attendance, and participants remaining at high risk suggest limits to what structured care alone can achieve. Engagement in continuous quality improvement to target other factors, including attendance and self-management, may deliver further improvements. © 2018 Diabetes UK.

A review of randomized controlled trials of medical record powered clinical decision support system to improve quality of diabetes care.

PubMed

Ali, Syed Mustafa; Giordano, Richard; Lakhani, Saima; Walker, Dawn Marie

2016-03-01

A gap between current diabetes care practice and recommended diabetes care standards has consistently been reported in the literature. Many IT-based interventions have been developed to improve adherence to the quality of care standards for chronic illness like diabetes. The widespread implementation of electronic medical/health records has catalyzed clinical decision support systems (CDSS) which may improve the quality of diabetes care. Therefore, the objective of the review is to evaluate the effectiveness of CDSS in improving quality of type II diabetes care. Moreover, the review aims to highlight the key indicators of quality improvement to assist policy makers in development of future diabetes care policies through the integration of information technology and system. Setting inclusion criteria, a systematic literature search was conducted using Medline, Web of Science and Science Direct. Critical Appraisal Skills Programme (CASP) tools were used to evaluate the quality of studies. Eight randomized controlled trials (RCTs) were selected for the review. In the selected studies, seventeen clinical markers of diabetes care were discussed. Three quality of care indicators were given more importance in monitoring the progress of diabetes care, which is consistent with National Institute for Health and Care Excellence (NICE) guidelines. The presence of these indicators in the studies helped to determine which studies were selected for review. Clinical- and process-related improvements are compared between intervention group using CDSS and control group with usual care. Glycated hemoglobin (HbA1c), low density lipid cholesterol (LDL-C) and blood pressure (BP) were the quality of care indicators studied at the levels of process of care and clinical outcome. The review has found both inconsistent and variable results for quality of diabetes care measures. A significant improvement has been found in the process of care for all three measures of quality of diabetes care

Do Diabetic Patients Living in Racially Segregated Neighborhoods Experience Different Access and Quality of Care?

PubMed Central

Chan, Kitty S.; Gaskin, Darrell J.; Dinwiddie, Gniesha Y.; McCleary, Rachael

2012-01-01

Background Place of residence, particularly residential segregation, has been implicated in health and health care disparities. However, prior studies have not focused on care for diabetes, a prevalent condition for minority populations. Objective To examine the association of residential segregation with a range of access and quality of care outcomes among Black and Hispanic diabetics using a nationally representative U.S. sample. Research Design Cross-sectional study using data for 1598 adult diabetics from the 2006 Medical Expenditure Panel Survey (MEPS) linked to residential segregation information for Blacks and Hispanics based on the 2000 census. Relationships of five dimensions of residential segregation (dissimilarity, isolation, clustering, concentration and centralization) with access and quality of care outcomes were examined using linear, logistic and multinomial logistic regression models, controlling for respondent characteristics and community utilization and hospital capacity. Results Black and Hispanic diabetics had comparable or better access to providers, but received fewer recommended services. Living in a segregated community was associated with more recommended services received, but also problems with seeing a specialist. The relationship of residential segregation to diabetes care varied depending on type of segregation and race/ethnic group assessed. Conclusions Residential segregation influences the care experience of diabetics in the U.S. Our study highlights the importance of investigating how different types of segregation may affect diabetes care received by patients from different race and ethnic groups. PMID:22525608

Relation Between the Level of American Indian and Alaska Native Diabetes Education Program Services and Quality-of-Care Indicators

PubMed Central

Noonan, Carolyn; Goldberg, Jack H.; Valdez, S. Lorraine; Brown, Tammy L.; Manson, Spero M.; Acton, Kelly

2008-01-01

Objectives. We examined the relation between the level of diabetes education program services in the Indian Health Service (IHS) and indicators of the quality of diabetes care to determine if more-comprehensive diabetes services were associated with better quality of diabetes care. Methods. In this cross-sectional study, we used the IHS Integrated Diabetes Education Recognition Program to rank program services into 1 of 3 levels of comprehensiveness, ranging from lowest (developmental) to highest (integrated). We compared quality-of-care indicators among programs of differing levels with the 2001 IHS Diabetes Care and Outcomes Audit. Quality indicators included patients having recommended yearly examinations, education, and laboratory tests and achieving recommended levels of intermediate outcomes of care. Results. Most of the 86 participating programs were classified at or below the developmental level; only 9 programs (11%) were ranked at higher levels. After adjusting for patient characteristics, program factors, and correlation of patients within programs, we associated programs that were more comprehensive with higher completion rates of yearly lipid and hemoglobin A1C tests (P < .05). Conclusions. System-wide improvements in diabetes education are associated with better diabetes care. The results can help inform the development of diabetes education programs. PMID:18511737

Determinants of Quality of Life in Primary Care Patients with Diabetes: Implications for Social Workers

ERIC Educational Resources Information Center

Ayalon, Liat; Gross, Revital; Tabenkin, Hava; Porath, Avi; Heymann, Anthony; Porter, Boaz

2008-01-01

Using a cross-sectional design of 400 primary care patients with diabetes, the authors evaluated demographics, health status, subjective health and mental health, health behaviors, health beliefs, knowledge of diabetes treatment, satisfaction with medical care, and quality of medical care as potential predictors of QoL and QoL in the hypothetical…

Quality improvement strategies at primary care level to reduce inequalities in diabetes care: an equity-oriented systematic review.

PubMed

Terens, Natalie; Vecchi, Simona; Bargagli, Anna Maria; Agabiti, Nera; Mitrova, Zuzana; Amato, Laura; Davoli, Marina

2018-05-29

There is evidence that disparities exist in diabetes prevalence, access to diabetes care, diabetes-related complications, and the quality of diabetes care. A wide range of interventions has been implemented and evaluated to improve diabetes care. We aimed to review trials of quality improvement (QI) interventions aimed to reduce health inequities among people with diabetes in primary care and to explore the extent to which experimental studies addressed and reported equity issues. Pubmed, EMBASE, CINAHL, and the Cochrane Library were searched to identify randomized controlled studies published between January 2005 and May 2016. We adopted the PROGRESS Plus framework, as a tool to explore differential effects of QI interventions across sociodemographic and economic factors. From 1903 references fifty-eight randomized trials met the inclusion criteria (with 17.786 participants), mostly carried out in USA. The methodological quality was good for all studies. Almost all studies reported the age, gender/sex and race distribution of study participants. The majority of trials additionally used at least one further PROGRESS-Plus factor at baseline, with education being the most commonly used, followed by income (55%). Large variation was observed between these studies for type of interventions, target populations, and outcomes evaluated. Few studies examined differential intervention effects by PROGRESS-plus factors. Existing evidence suggests that some QI intervention delivered in primary care can improve diabetes-related health outcomes in social disadvantaged population subgroups such as ethnic minorities. However, we found very few studies comparing health outcomes between population subgroups and reporting differential effect estimates of QI interventions. This review provides evidence that QI interventions for people with diabetes is feasible to implement and highly acceptable. However, more research is needed to understand their effective components as well as the

[Diabetes related visual disability incidence as an indicator of the quality of ophthalmic and diabetic care].

PubMed

Bandurska-Stankiewicz, Elzbieta; Wiatr, Dorota

2007-01-01

This study was to investigate the incidence of blindness due to diabetes in the years 1989-2003, and to compare the studied coefficients in view of the changes in diabetic and ophthalmic care proceeding in the region. Studies on the incidence of diabetes related blindness were conducted in the Warmia & Mazury Region in the years 1989-2003 among patients with type 1 (DM1) and type 2 (DM2) diabetes. Blindness recognized according to the WHO criteria. The incidence rate (IR) was expressed as the number of new blindness cases per 100,000 population per year. The register covered 274 patients visually disabled due to diabetes, in this 69 with DM1, in average of age 47.1, and 205 with DM2, in average of age 65.6. At the beginning of the observation IR varied with the highest in 1995--4.8/100000 (CI: 3.2-6.3). This period was characterized by limited access of patients to diabetologists and laserotherapy. From 1996 it decreased from 4.3/100000 (CI: 2.8-5.7) to 0.9/100000 (CI: 0.2-1.6) in 2003--a new programme of diabetic care with early detection and treatment of retinopathy was introduced. A growth of funds for basic and outpatient clinic specialist care was observed. Analysis of diabetes related blindness is a good indicator of the quality of diabetic and ophthalmic care.

Public reporting helped drive quality improvement in outpatient diabetes care among Wisconsin physician groups

PubMed Central

Smith, Maureen A.; Wright, Alexandra; Queram, Christopher; Lamb, Geoffrey C.

2012-01-01

Public reporting on the quality of ambulatory health care is growing, but knowledge of how physician groups respond to such reporting has not kept pace. We examined responses to public reporting on the quality of diabetes care in 409 primary care clinics within seventeen large, multispecialty physician groups. We determined that a focus on publicly reported metrics, along with participation in large or externally sponsored projects, increased a clinic’s implementation of diabetes improvement interventions. Clinics were also more likely to implement interventions in more recent years. Public reporting helped drive both early implementation of a single intervention and ongoing implementation of multiple simultaneous interventions. To fully engage physician groups, accountability metrics should be structured to capture incremental improvements in quality, thereby rewarding both early and ongoing improvement activities. PMID:22392668

Quality of diabetes care worldwide and feasibility of implementation of the Alphabet Strategy: GAIA project (Global Alphabet Strategy Implementation Audit).

PubMed

Lee, James D; Saravanan, Ponnusamy; Varadhan, Lakshminarayanan; Morrissey, John R; Patel, Vinod

2014-10-11

The Alphabet Strategy (AS) is a diabetes care checklist ensuring "important, simple things are done right all the time." Current audits of diabetes care in developed countries reveal wide variations in quality with performance of care processes frequently sub-optimal. This study had three components:• an audit to assess diabetes care quality worldwide,• a questionnaire study seeking opinions on the merits of the AS,• a pilot study to assess the practicality of implementation of the AS in a low socioeconomic setting. Audit data was collected from 52 centres across 32 countries. Data from 4537 patients were converted to Quality and Outcome Framework (QOF) scores to enable inter-centre comparison. These were compared to each country's Gross Domestic Product (GDP), and Total Health Expenditure percentage per capita (THE%). The opinions of diabetes patients and healthcare professionals from the diabetes care team at each of these centres were sought through a structured questionnaire. A retrospective audit on 100 randomly selected case notes was conducted prior to AS implementation in a diabetes outpatient clinic in India, followed by a prospective audit after four months to assess its impact on care quality. QOF scores showed wide variation across the centres (mean 49.0, range 10.2-90.1). Although there was a positive relationship between GDP and THE% to QOF scores, there were exceptions. 91% of healthcare professionals felt the AS approach was practical. Patients found the checklist to be a useful education tool. Significant improvements in several aspects of care as well as 36% improvement in QOF score were seen following implementation. International centres observed large variations in care quality, with standards frequently sub-optimal. 71% of health care professionals would consider adopting the AS in their daily practice. Implementation in a low resource country resulted in significant improvements in some aspects of diabetes care. The AS checklist for

Association between quality management and performance indicators in Dutch diabetes care groups: a cross-sectional study.

PubMed

Campmans-Kuijpers, Marjo J E; Baan, Caroline A; Lemmens, Lidwien C; Klomp, Maarten L H; Romeijnders, Arnold C M; Rutten, Guy E H M

2015-05-11

To enhance the quality of diabetes care in the Netherlands, so-called care groups with three to 250 general practitioners emerged to organise and coordinate diabetes care. This introduced a new quality management level in addition to the quality management of separate general practices. We hypothesised that this new level of quality management might be associated with the aggregate performance indicators on the patient level. Therefore, we aimed to explore the association between quality management at the care group level and its aggregate performance indicators. A cross-sectional study. All Dutch care groups (n=97). 23 care groups provided aggregate register-based performance indicators of all their practices as well as data on quality management measured with a questionnaire filled out by 1 or 2 of their quality managers. The association between quality management, overall and in 6 domains ('organisation of care', 'multidisciplinary teamwork', 'patient centredness', 'performance management', 'quality improvement policy' and 'management strategies') on the one hand and 3 process indicators (the percentages of patients with at least 1 measurement of glycated haemoglobin, lipid profile and systolic blood pressure), and 3 intermediate outcome indicators (the percentages of patients with glycated haemoglobin below 53 mmol/mol (7%); low-density lipoprotein cholesterol below 2.5 mmol/L; and systolic blood pressure below 140 mm Hg) by weighted univariable linear regression. The domain 'management strategies' was significantly associated with the percentage of patients with a glycated haemoglobin <53 mmol/mol (β 0.28 (0.09; 0.46) p=0.01) after correction for multiple testing. The other domains as well as overall quality management were not associated with aggregate process or outcome indicators. This first exploratory study on quality management showed weak or no associations between quality management of diabetes care groups and their performance. It remains

The association between improved quality diabetes indicators, health outcomes and costs: towards constructing a "business case" for quality of diabetes care--a time series study.

PubMed

Wilf-Miron, Rachel; Bolotin, Arkadi; Gordon, Nesia; Porath, Avi; Peled, Ronit

2014-12-01

In primary health care systems where member's turnover is relatively low, the question, whether investment in quality of care improvement can make a business case, or is cost effective, has not been fully answered.The objectives of this study were: (1) to investigate the relationship between improvement in selected measures of diabetes (type 2) care and patients' health outcomes; and (2) to estimate the association between improvement in performance and direct medical costs. A time series study with three quality indicators - Hemoglobin A1c (HbA1c) testing, HbA1C and LDL- cholesterol (LDL-C) control - which were analyzed in patients with diabetes, insured by a large health fund. Health outcomes measures used: hospitalization days, Emergency Department (ED) visits and mortality. Poisson, GEE and Cox regression models were employed. Covariates: age, gender and socio-economic rank. 96,553 adult (age >18) patients with diabetes were analyzed. The performance of the study indicators, significantly and steadily improved during the study period (2003-2009). Poor HbA1C (>9%) and inappropriate LDL-C control (>100 mg/dl) were significantly associated with number of hospitalization days. ED visits did not achieve statistical significance. Improvement in HbA1C control was associated with an annual average of 2% reduction in hospitalization days, leading to substantial reduction in tertiary costs. The Hazard ratio for mortality, associated with poor HbA1C and LDL-C, control was 1.78 and 1.17, respectively. Our study demonstrates the effect of continuous improvement in quality care indicators, on health outcomes and resource utilization, among patients with diabetes. These findings support the business case for quality, especially in healthcare systems with relatively low enrollee turnover, where providers, in the long term, could "harvest" their investments in improving quality.

Quality of Diabetes Care: The Challenges of an Increasing Epidemic in Mexico. Results from Two National Health Surveys (2006 and 2012).

PubMed

Flores-Hernández, Sergio; Saturno-Hernández, Pedro J; Reyes-Morales, Hortensia; Barrientos-Gutiérrez, Tonatiuh; Villalpando, Salvador; Hernández-Ávila, Mauricio

2015-01-01

The quality of diabetes care remains suboptimal according to numerous studies assessing the achievement of quality indicators for diabetes care in various healthcare settings. We report about global and specific quality indicators for diabetes care and their association to glycemic control at the population level in two national health surveys in Mexico. We conducted a cross-sectional analysis of the 2006 and 2012 National Health Surveys in Mexico. We examined quality of care for 2,965 and 4,483 adults (≥ 20 years) with diagnosed type 2 diabetes using fourteen simple and two composite indicators derived from self-reported information. In a subsample for both surveys, glycated hemoglobin (HbA1c) was measured at the time of the interview. We obtained survey weight-adjusted estimators using multiple regression models (logistic and linear) with combined data files, including survey year as covariate to assess change. Global quality of care in 2012 was 40.8%, with a relative improvement of 11.7% between 2006 and 2012. Detections of cardiovascular disease risk factors (dyslipidemia and hypertension) were the indicators with the highest improvement, while non-pharmaceutical treatment and diabetic foot exams showed minor changes. We found a significant association between the quality of the process of diabetes care and glycemic control (OR 2.53, 95% CI 1.63-3.94). Age more than 65 years old, the type of health subsystem, gender (males), and high socio-economic status were also significantly associated to glycemic control. Quality diabetes care and glycemic control improved and are significantly associated. However, according to international standards, the current situation remains suboptimal. A more holistic approach is needed, with an emphasis on improving quality in outpatient care.

Increasing Consumer Engagement by Tailoring a Public Reporting Website on the Quality of Diabetes Care: A Qualitative Study

PubMed Central

Bednarz, Lauren; Nordby, Peter A; Fink, Jennifer; Greenlee, Robert T; Bolt, Daniel; Magnan, Elizabeth M

2016-01-01

Background The majority of health care utilization decisions in the United States are made by persons with multiple chronic conditions. Existing public reports of health system quality do not distinguish care for these persons and are often not used by the consumers they aim to reach. Objective Our goal was to determine if tailoring quality reports to persons with diabetes mellitus and co-occurring chronic conditions would increase user engagement with a website that publicly reports the quality of diabetes care. Methods We adapted an existing consumer-focused public reporting website using adult learning theory to display diabetes quality reports tailored to the user’s chronic condition profile. We conducted in-depth cognitive interviews with 20 individuals who either had diabetes and/or cared for someone with diabetes to assess the website. Interviews were audiotaped and transcribed, then analyzed using thematic content analysis. Results Three themes emerged that suggested increased engagement from tailoring the site to a user’s chronic conditions: ability to interact, relevance, and feeling empowered to act. Conclusions We conclude that tailoring can be used to improve public reporting sites for individuals with chronic conditions, ultimately allowing consumers to make more informed health care decisions. PMID:28003173

High quality diabetes care: testing the effectiveness of strategies of regional implementation teams.

PubMed

Drach-Zahavy, Anat; Shadmi, Efrat; Freund, Anat; Goldfracht, Margalit

2009-01-01

The purpose of this article is to identify and test the effectiveness of work strategies employed by regional implementation teams to attain high quality care for diabetes patients. The study was conducted in a major health maintenance organization (HMO) that provides care for 70 per cent of Israel's diabetes patients. A sequential mixed model design, combining qualitative and quantitative methods was employed. In-depth interviews were conducted with members of six regional implementation teams, each responsible for the care of 25,000-34,000 diabetic patients. Content analysis of the interviews revealed that teams employed four key strategies: task-interdependence, goal-interdependence, reliance on top-down standardised processes and team-learning. These strategies were used to predict the mean percentage performance of eight evidence-based indicators of diabetes care: percentage of patients with HbA1c < 7 per cent, blood pressure < or = 130/80 and cholesterol < or = 100; and performance of: HbA1c tests, LDL cholesterol tests, blood pressure measurements, urine protein tests, and ophthalmic examinations. Teams were found to vary in their use of the four strategies. Mixed linear models analysis indicated that type of indicator (simple process, compound process, and outcome) and goal interdependence were significantly linked to team effectiveness. For simple-process indicators, reliance on top-down standardised processes led to team effectiveness, but for outcome measures this strategy was ineffective, and even counter-effective. For outcome measures, team-learning was more beneficial. The findings have implications for the management of chronic diseases. The advantage of allowing team members flexibility in the choice of the best work strategy to attain high quality diabetes care is attested.

Counting on commitment; the quality of primary care-led diabetes management in a system with minimal incentives

PubMed Central

2011-01-01

Background The aim of the present study was to assess the performance of three primary care-led initiatives providing structured care to patients with Type 2 diabetes in Ireland, a country with minimal incentives to promote the quality of care. Methods Data, from three primary care initiatives, were available for 3010 adult patients with Type 2 diabetes. Results were benchmarked against the national guidelines for the management of Type 2 diabetes in the community and results from the National Diabetes Audit (NDA) for England (2008/2009) and the Scottish Diabetes Survey (2009). Results The recording of clinical processes of care was similar to results in the UK however the recording of lifestyle factors was markedly lower. Recording of HbA1c, blood pressure and lipids exceeded 85%. Recording of retinopathy screening (71%) was also comparable to England (77%) and Scotland (90%). Only 63% of patients had smoking status recorded compared to 99% in Scotland while 70% had BMI recorded compared to 89% in England. A similar proportion of patients in this initiative and the UK achieved clinical targets. Thirty-five percent of patients achieved a target HbA1c of < 6.5% (< 48 mmol/mol) compared to 25% in England. Applying the NICE target for blood pressure (≤ 140/80 mmHg), 54% of patients reached this target comparable to 60% in England. Slightly less patients were categorised as obese (> 30 kg/m2) in Ireland (50%, n = 1060) compared to Scotland (54%). Conclusions This study has demonstrated what can be achieved by proactive and interested health professionals in the absence of national infrastructure to support high quality diabetes care. The quality of primary care-led diabetes management in the three initiatives studied appears broadly consistent with results from the UK with the exception of recording lifestyle factors. The challenge facing health systems is to establish quality assurance a responsibility for all health care professionals rather than the subject of

Counting on commitment; the quality of primary care-led diabetes management in a system with minimal incentives.

PubMed

Mc Hugh, Sheena; Marsden, Paul; Brennan, Carmel; Murphy, Katie; Croarkin, Celine; Moran, Joe; Harkins, Velma; Perry, Ivan J

2011-12-28

The aim of the present study was to assess the performance of three primary care-led initiatives providing structured care to patients with Type 2 diabetes in Ireland, a country with minimal incentives to promote the quality of care. Data, from three primary care initiatives, were available for 3010 adult patients with Type 2 diabetes. Results were benchmarked against the national guidelines for the management of Type 2 diabetes in the community and results from the National Diabetes Audit (NDA) for England (2008/2009) and the Scottish Diabetes Survey (2009). The recording of clinical processes of care was similar to results in the UK however the recording of lifestyle factors was markedly lower. Recording of HbA1c, blood pressure and lipids exceeded 85%. Recording of retinopathy screening (71%) was also comparable to England (77%) and Scotland (90%). Only 63% of patients had smoking status recorded compared to 99% in Scotland while 70% had BMI recorded compared to 89% in England. A similar proportion of patients in this initiative and the UK achieved clinical targets. Thirty-five percent of patients achieved a target HbA1c of < 6.5% (< 48 mmol/mol) compared to 25% in England. Applying the NICE target for blood pressure (≤ 140/80 mmHg), 54% of patients reached this target comparable to 60% in England. Slightly less patients were categorised as obese (> 30 kg/m²) in Ireland (50%, n = 1060) compared to Scotland (54%). This study has demonstrated what can be achieved by proactive and interested health professionals in the absence of national infrastructure to support high quality diabetes care. The quality of primary care-led diabetes management in the three initiatives studied appears broadly consistent with results from the UK with the exception of recording lifestyle factors. The challenge facing health systems is to establish quality assurance a responsibility for all health care professionals rather than the subject of special interest for a few.

Quality improvements in diabetes care, how holistic have they been? A case-study from the United Kingdom

PubMed Central

2014-01-01

Aims As quality in diabetes care includes patient centred support for self-management, investigating patients’ experiences upon diagnosis can help improve access to this element of care among diverse populations. This research explored this care in the context of recent national quality improvement initiatives which support self-management. Methods South Asian and White European patients over 16 years with a recent (< 1 year) diagnosis of diabetes were recruited from 18 General Practitioner (GP) practices in three UK locations - Luton, West London and Leicester. A semi-structured qualitative interview was conducted with 47 patients. Results Twenty one out of 47 (45%) reported unmet support and information needs at diagnosis. Although there was a small proportion of participants (8 out of 47, 17% of all respondents) who felt they did not require any help or support with managing their diabetes because their GP had provided comprehensive and efficient care, there was an equal number who voiced a negative view of the care they had received to date. This concerned information giving, support and communication, suggesting that recently implemented national quality improvement interventions may not have been successful in improving all aspects of diabetes care, particularly those encouraging self-management. The emerging analysis led to consideration of concordance as an important concept through which to understand inequalities and improve access to quality diabetes care. In order to encourage self-management from the start, care providers need to be cognisant that patients are not homogeneous and be responsive to their different information needs and emotional responses to diagnosis. Conclusions In order to support self-management and deliver patient centred care in diverse populations, care providers will need to be adaptable to individual needs around diagnosis. PMID:24731304

Association between quality management and performance indicators in Dutch diabetes care groups: a cross-sectional study

PubMed Central

Campmans-Kuijpers, Marjo J E; Baan, Caroline A; Lemmens, Lidwien C; Klomp, Maarten L H; Romeijnders, Arnold C M; Rutten, Guy E H M

2015-01-01

Objectives To enhance the quality of diabetes care in the Netherlands, so-called care groups with three to 250 general practitioners emerged to organise and coordinate diabetes care. This introduced a new quality management level in addition to the quality management of separate general practices. We hypothesised that this new level of quality management might be associated with the aggregate performance indicators on the patient level. Therefore, we aimed to explore the association between quality management at the care group level and its aggregate performance indicators. Design A cross-sectional study. Setting All Dutch care groups (n=97). Participants 23 care groups provided aggregate register-based performance indicators of all their practices as well as data on quality management measured with a questionnaire filled out by 1 or 2 of their quality managers. Primary outcomes The association between quality management, overall and in 6 domains (‘organisation of care’, ‘multidisciplinary teamwork’, ‘patient centredness’, ‘performance management’, ‘quality improvement policy’ and ‘management strategies’) on the one hand and 3 process indicators (the percentages of patients with at least 1 measurement of glycated haemoglobin, lipid profile and systolic blood pressure), and 3 intermediate outcome indicators (the percentages of patients with glycated haemoglobin below 53 mmol/mol (7%); low-density lipoprotein cholesterol below 2.5 mmol/L; and systolic blood pressure below 140 mm Hg) by weighted univariable linear regression. Results The domain ‘management strategies’ was significantly associated with the percentage of patients with a glycated haemoglobin <53 mmol/mol (β 0.28 (0.09; 0.46) p=0.01) after correction for multiple testing. The other domains as well as overall quality management were not associated with aggregate process or outcome indicators. Conclusions This first exploratory study on quality management showed weak

Quality of Diabetes Care: The Challenges of an Increasing Epidemic in Mexico. Results from Two National Health Surveys (2006 and 2012)

PubMed Central

Flores-Hernández, Sergio; Saturno-Hernández, Pedro J.; Reyes-Morales, Hortensia; Barrientos-Gutiérrez, Tonatiuh; Villalpando, Salvador; Hernández-Ávila, Mauricio

2015-01-01

Background The quality of diabetes care remains suboptimal according to numerous studies assessing the achievement of quality indicators for diabetes care in various healthcare settings. We report about global and specific quality indicators for diabetes care and their association to glycemic control at the population level in two national health surveys in Mexico. Methods We conducted a cross-sectional analysis of the 2006 and 2012 National Health Surveys in Mexico. We examined quality of care for 2,965 and 4,483 adults (≥ 20 years) with diagnosed type 2 diabetes using fourteen simple and two composite indicators derived from self-reported information. In a subsample for both surveys, glycated hemoglobin (HbA1c) was measured at the time of the interview. We obtained survey weight-adjusted estimators using multiple regression models (logistic and linear) with combined data files, including survey year as covariate to assess change. Results Global quality of care in 2012 was 40.8%, with a relative improvement of 11.7% between 2006 and 2012. Detections of cardiovascular disease risk factors (dyslipidemia and hypertension) were the indicators with the highest improvement, while non-pharmaceutical treatment and diabetic foot exams showed minor changes. We found a significant association between the quality of the process of diabetes care and glycemic control (OR 2.53, 95% CI 1.63-3.94). Age more than 65 years old, the type of health subsystem, gender (males), and high socio-economic status were also significantly associated to glycemic control. Conclusions Quality diabetes care and glycemic control improved and are significantly associated. However, according to international standards, the current situation remains suboptimal. A more holistic approach is needed, with an emphasis on improving quality in outpatient care. PMID:26230991

The association of cumulative discrimination on quality of care, patient-centered care, and dissatisfaction with care in adults with type 2 diabetes.

PubMed

Cykert, David M; Williams, Joni S; Walker, Rebekah J; Davis, Kimberly S; Egede, Leonard E

2017-01-01

Discrimination is linked to negative health outcomes, but little research has investigated how the cumulative effect of discrimination impacts perceptions of care. This study investigated the influence of cumulative perceived discrimination on quality of care, patient-centeredness, and dissatisfaction with care in adults with type 2 diabetes. Six hundred two patients from two primary care clinics in Charleston, SC. Linear regression models assessed associations between perceived discrimination and quality of care, patient-centered care, and dissatisfaction with care. The models control for race, site, age, gender, marital status, duration of diabetes, education, hours worked weekly, income, and health status. The mean age was 61.5years, with 66.3% non-Hispanic blacks, and 41.9% earning less than $20,000 annually. In final adjusted analyses, lower patient-centered care was associated with a higher discrimination score (β=-0.28; p=0.006), reporting at least 1 category of discrimination (β=-1.47; p=0.002), and reporting at least 2 categories of discrimination (β=-1.34; p=0.004). Dissatisfaction with care was associated with at least 2 categories of discrimination (β=0.45; p=0.002). No significant associations were seen with quality of care indicators. Increased cumulative discrimination was associated with decreased feeling of patient-centeredness and increased dissatisfaction with care. However, these perceptions of discrimination were not significantly associated with quality indicators. Copyright © 2017 Elsevier Inc. All rights reserved.

Impact of an EHR-based diabetes management form on quality and outcomes of diabetes care in primary care practices.

PubMed

Herrin, Jeph; da Graca, Briget; Aponte, Phil; Stanek, H Greg; Cowling, Terianne; Fullerton, Cliff; Hollander, Priscilla; Ballard, David J

2015-01-01

Health information technology shows promise for improving chronic disease care. This study assessed the impact of a diabetes management form (DMF), accessible within an electronic health record. From 2007 to 2009, 2108 diabetes patients were seen in 20 primary care practices; 1103 visits involved use of the DMF in 2008. The primary outcome was "optimal care": HbA1c ≤8%, low-density lipoprotein (LDL) cholesterol <100 mg/dL, blood pressure <130/80 mm Hg, not smoking, and aspirin prescription in patients ≥40 years. After adjusting for number of visits, age, sex, and insulin use, DMF-exposed patients showed less improvement in attaining "optimal care" (estimated difference-in-difference [DID] = -2.06 percentage points; P < .001), LDL cholesterol (DID = -2.30; P = .023), blood pressure (DID = -3.05; P < .001), and total cholesterol (DID = -0.47; P = .004) targets. Documented microalbumin tests, aspirin prescription, and eye and foot exams increased more. Thus, DMF use was associated with smaller gains in achieving evidence-based targets, but greater improvement in documented delivery of care. © 2013 by the American College of Medical Quality.

A diabetes dashboard and physician efficiency and accuracy in accessing data needed for high-quality diabetes care.

PubMed

Koopman, Richelle J; Kochendorfer, Karl M; Moore, Joi L; Mehr, David R; Wakefield, Douglas S; Yadamsuren, Borchuluun; Coberly, Jared S; Kruse, Robin L; Wakefield, Bonnie J; Belden, Jeffery L

2011-01-01

We compared use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record (EHR) screens to find data needed for ambulatory diabetes care. We performed a usability study, including a quantitative time study and qualitative analysis of information-seeking behaviors. While being recorded with Morae Recorder software and "think-aloud" interview methods, 10 primary care physicians first searched their EHR for 10 diabetes data elements using a conventional approach for a simulated patient, and then using a new diabetes dashboard for another. We measured time, number of mouse clicks, and accuracy. Two coders analyzed think-aloud and interview data using grounded theory methodology. The mean time needed to find all data elements was 5.5 minutes using the conventional approach vs 1.3 minutes using the diabetes dashboard (P <.001). Physicians correctly identified 94% of the data requested using the conventional method, vs 100% with the dashboard (P <.01). The mean number of mouse clicks was 60 for conventional searching vs 3 clicks with the diabetes dashboard (P <.001). A common theme was that in everyday practice, if physicians had to spend too much time searching for data, they would either continue without it or order a test again. Using a patient-specific diabetes dashboard improves both the efficiency and accuracy of acquiring data needed for high-quality diabetes care. Usability analysis tools can provide important insights into the value of optimizing physician use of health information technologies.

Change in quality management in diabetes care groups and outpatient clinics after feedback and tailored support.

PubMed

Campmans-Kuijpers, Marjo J; Baan, Caroline A; Lemmens, Lidwien C; Rutten, Guy E

2015-02-01

To assess the change in level of diabetes quality management in primary care groups and outpatient clinics after feedback and tailored support. This before-and-after study with a 1-year follow-up surveyed quality managers on six domains of quality management. Questionnaires measured organization of care, multidisciplinary teamwork, patient centeredness, performance results, quality improvement policy, and management strategies (score range 0-100%). Based on the scores, responders received feedback and a benchmark and were granted access to a toolbox of quality improvement instruments. If requested, additional support in improving quality management was available, consisting of an elucidating phone call or a visit from an experienced consultant. After 1 year, the level of quality management was measured again. Of the initially 60 participating care groups, 51 completed the study. The total quality management score improved from 59.8% (95% CI 57.0-62.6%) to 65.1% (62.8-67.5%; P < 0.0001). The same applied to all six domains. The feedback and benchmark improved the total quality management score (P = 0.001). Of the 44 participating outpatient clinics, 28 completed the study. Their total score changed from 65.7% (CI 60.3-71.1%) to 67.3% (CI 62.9-71.7%; P = 0.30). Only the results in the domain multidisciplinary teamwork improved (P = 0.001). Measuring quality management and providing feedback and a benchmark improves the level of quality management in care groups but not in outpatient clinics. The questionnaires might also be a useful asset for other diabetes care groups, such as Accountable Care Organizations. © 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

Increasing Consumer Engagement by Tailoring a Public Reporting Website on the Quality of Diabetes Care: A Qualitative Study.

PubMed

Smith, Maureen A; Bednarz, Lauren; Nordby, Peter A; Fink, Jennifer; Greenlee, Robert T; Bolt, Daniel; Magnan, Elizabeth M

2016-12-21

The majority of health care utilization decisions in the United States are made by persons with multiple chronic conditions. Existing public reports of health system quality do not distinguish care for these persons and are often not used by the consumers they aim to reach. Our goal was to determine if tailoring quality reports to persons with diabetes mellitus and co-occurring chronic conditions would increase user engagement with a website that publicly reports the quality of diabetes care. We adapted an existing consumer-focused public reporting website using adult learning theory to display diabetes quality reports tailored to the user's chronic condition profile. We conducted in-depth cognitive interviews with 20 individuals who either had diabetes and/or cared for someone with diabetes to assess the website. Interviews were audiotaped and transcribed, then analyzed using thematic content analysis. Three themes emerged that suggested increased engagement from tailoring the site to a user's chronic conditions: ability to interact, relevance, and feeling empowered to act. We conclude that tailoring can be used to improve public reporting sites for individuals with chronic conditions, ultimately allowing consumers to make more informed health care decisions. ©Maureen A Smith, Lauren Bednarz, Peter A Nordby, Jennifer Fink, Robert T Greenlee, Daniel Bolt, Elizabeth M Magnan. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 21.12.2016.

Integrating palliative care with usual care of diabetic foot wounds.

PubMed

Dunning, Trisha

2016-01-01

Palliative care is a philosophy and a system for deciding care and can be used alone or integrated with usual chronic disease care. Palliative care encompasses end-of-life care. Palliative care aims to enhance quality of life, optimize function and manage symptoms including early in the course of chronic diseases. The purposes of this article are to outline palliative care and discuss how it can be integrated with usual care of diabetic foot wounds. Many people with diabetes who have foot wounds also have other comorbidities and diabetes complications such as cardiovascular and renal disease and depression, which affect medicine and other treatment choices, functional status, surgical risk and quality of life. Two broad of diabetic foot disease exist: those likely to heal but who could still benefit from integrated palliative care such as managing pain and those where healing is unlikely where palliation can be the primary focus. People with diabetes can die suddenly, although the life course is usually long with periods of stable and unstable disease. Many health professionals are reluctant to discuss palliative care or suggest people to document their end-of-life care preferences. If such preferences are not documented, the person might not achieve their desired death or place of death and health professionals and families can be confronted with difficult decisions. Palliative care can be integrated with usual foot care and is associated with improved function, better quality of life and greater patient and family satisfaction. Copyright © 2016 John Wiley & Sons, Ltd.

Stakeholders' perspectives on quality indicators for diabetes care: a qualitative study.

PubMed

Markhorst, Joekie; Martirosyan, Liana; Calsbeek, Hiske; Braspenning, Jozé

2012-01-01

Transparency in diabetes care requires quality indicators that are of interest to stakeholders in order to optimise their usage. Indicator development is often focused on consensus, and little is known about stakeholders' preferences for information on quality. To explore the preferences of consumers, providers, purchasers and policy makers for different quality domains and indicators in relation to the intended use of quality indicators. Between June and December 2009, 14 semi-structured interviews were held with stakeholders who have a decisive vote in the selection of the national indicator set for diabetes care in the Netherlands. The following subjects were explored: (1) the aims of using information on quality; (2) the interpretation of and preferences for the quality domains of safety, timeliness, effectiveness and patient-centredness in relation to the user aims; and (3) the preferences for structure, process or outcome indicators. Content analysis was used to analyse qualitative data. Stakeholders had similar and different aims according to their roles. The interpretations of quality domains varied greatly between the stakeholders. Besides differences in interpretation, their preferences were similar. Most stakeholders prioritised patient-centredness above the other domains of quality, ranked in order of priority as safety, effectiveness and timeliness, whereas purchasers also prioritised efficiency. All stakeholders preferred to use process indicators or a mix of process and outcome indicators. The preferences of the stakeholders for quality indicators seem to be neither well-refined nor congruent. The implementation of an indicator set can probably be improved if the stakeholders' definitions and preferences for quality domains become more explicit during the selection process for indicators.

Assessment of quality of care for the management of type 2 diabetes: a multicentre study from a developing country.

PubMed

Azam, Iqbal Syed; Khuwaja, Ali Khan; Rafique, Ghazala; White, Franklin

2010-01-01

Complications of diabetes can be prevented or delayed by providing high quality care. This study aimed to document the quality of care provided to people with type 2 diabetes in Pakistan and to identify the difference in care offered at various clinics. Cross-sectional multi-centre study. Interviews were undertaken with 672 people with type 2 diabetes attending three different types of diabetes clinic (private clinic (A), non-governmental organisation (B) and public clinic (C)) in Karachi, Pakistan. A structured questionnaire was used to collect socio-demographic and clinical information from patients; quality of care indicators were also confirmed by reference to patients' medical records. Overall, 68% (A: 92%, B: 58% and C: 52%, P<0.001) of study subjects were informed about diabetes complications. Blood pressure (BP) monitoring at every visit was completed for 80% of study respondents (A: 100%, B: 79% and C: 57%, P<0.001). Foot examination was infrequent (53%, A: 98%, B: 52% and C: 8% (P<0.001). Lipid profiles of 48% of patients had been done in the past 12 months (A: 77%, B: 16% and C: 50%, P<0.001). Microalbumin testing had been performed in 32% of patients in the previous year (A: 77%, B: 09% and C: 05%; P<0.001). Most participants had elevated glycaemic (58.2%) and BP levels (84.7%) with higher prevalence among people who attended clinics B and C (P<0.001). Overall, 82.6% of study subjects had an elevated body mass index; this was almost equally prevalent across clinics. Many patients with type 2 diabetes do not receive optimal diabetes care in Karachi. Among the different settings, care provided in private health sector clinics was of a better standard. However, our results reveal a need for overall improvement in the quality of diabetes care. Further research is also needed to evaluate the reasons for poor diabetes care, and to identify the most cost-effective means to address these.

Use of multiple methods to determine factors affecting quality of care of patients with diabetes.

PubMed

Khunti, K

1999-10-01

The process of care of patients with diabetes is complex; however, GPs are playing a greater role in its management. Despite the research evidence, the quality of care of patients with diabetes is variable. In order to improve care, information is required on the obstacles faced by practices in improving care. Qualitative and quantitative methods can be used for formation of hypotheses and the development of survey procedures. However, to date few examples exist in general practice research on the use of multiple methods using both quantitative and qualitative techniques for hypothesis generation. We aimed to determine information on all factors that may be associated with delivery of care to patients with diabetes. Factors for consideration on delivery of diabetes care were generated by multiple qualitative methods including brainstorming with health professionals and patients, a focus group and interviews with key informants which included GPs and practice nurses. Audit data showing variations in care of patients with diabetes were used to stimulate the brainstorming session. A systematic literature search focusing on quality of care of patients with diabetes in primary care was also conducted. Fifty-four potential factors were identified by multiple methods. Twenty (37.0%) were practice-related factors, 14 (25.9%) were patient-related factors and 20 (37.0%) were organizational factors. A combination of brainstorming and the literature review identified 51 (94.4%) factors. Patients did not identify factors in addition to those identified by other methods. The complexity of delivery of care to patients with diabetes is reflected in the large number of potential factors identified in this study. This study shows the feasibility of using multiple methods for hypothesis generation. Each evaluation method provided unique data which could not otherwise be easily obtained. This study highlights a way of combining various traditional methods in an attempt to overcome the

Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study.

PubMed

Mundt, Marlon P; Agneessens, Filip; Tuan, Wen-Jan; Zakletskaia, Larissa I; Kamnetz, Sandra A; Gilchrist, Valerie J

2016-06-01

Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care. To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes. A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling. 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013. Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (rate ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes. Primary care teams which relied on frequent daily face-to-face communication among more team members, and had a single RN communicating patient care

Primary care team communication networks, team climate, quality of care, and medical costs for patients with diabetes: A cross-sectional study

PubMed Central

Mundt, Marlon P.; Agneessens, Filip; Tuan, Wen-Jan; Zakletskaia, Larissa I.; Kamnetz, Sandra A.; Gilchrist, Valerie J.

2016-01-01

Background Primary care teams play an important role in providing the best quality of care to patients with diabetes. Little evidence is available on how team communication networks and team climate contribute to high quality diabetes care. Objective To determine whether primary care team communication and team climate are associated with health outcomes, health care utilization, and associated costs for patients with diabetes. Methods A cross-sectional survey of primary care team members collected information on frequency of communication with other care team members about patient care and on team climate. Patient outcomes (glycemic, cholesterol, and blood pressure control, urgent care visits, emergency department visits, hospital visit days, medical costs) in the past 12 months for team diabetes patient panels were extracted from the electronic health record. The data were analyzed using nested (clinic/team/patient) generalized linear mixed modeling. Participants 155 health professionals at 6 U.S. primary care clinics participated from May through December 2013. Results Primary care teams with a greater number of daily face-to-face communication ties among team members were associated with 52% (Rate Ratio=0.48, 95% CI: 0.22, 0.94) fewer hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team diabetes patient in the past 12 months. In contrast, for each additional registered nurse (RN) who reported frequent daily face-to-face communication about patient care with the primary care practitioner (PCP), team diabetes patients had less-controlled HbA1c (Odds Ratio=0.83, 95% CI: 0.66, 0.99), increased hospital days (RR=1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β=US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes. Conclusions Primary care teams which relied on frequent daily face-to-face communication among more

[Audit and feedback, and continuous quality improvement strategies to improve the quality of care for type 2 diabetes: a systematic review of literature].

PubMed

Vecchi, Simona; Agabiti, Nera; Mitrova, Susanna; Cacciani, Laura; Amato, Laura; Davoli, Marina; Bargagli, Anna Maria

2016-01-01

we analysed evidence on effective interventions to improve the quality of care and management in patients with diabetes type 2. This review focuses particularly on audit and feedback intervention, targeted to healthcare providers, and continuous quality improvement (CQI) involving health professionals and health care systems, respectively. we searched The Cochrane Library, PubMed, and EMBASE (search period: January 2005-December 2015) to identify systematic reviews (SR) and randomized controlled trials (RCTs) considering patients' outcomes and process measures as quality indicators in diabetes care. Selection of studies and data extraction were carried out independently by two reviewers. Methodological quality of individual studies was assessed using the checklist «Assessment of methodological quality of systematic review» (AMSTAR) and the Cochrane's tool, respectively. We produced summaries of results for each study design. the search process resulted in 810 citations. One SR and 7 RCTs that compared any intervention in which audit and feedback and CQI was a component vs. other interventions were selected. The SR found that audit and feedback activity was associated with improvements of glycaemic (mean difference: 0.26; 95%CI 0.08;0.44) and cholesterol control (mean difference: 0.03; 95%CI -0.04;0.10). CQI interventions were not associated with an improvement of quality of diabetes care. The RCTs considered in this review compared a broad range of interventions including feedback as unique activity or as part of more complex strategies. The methodological quality was generally poor in all the included trials. the available evidence suggests that audit and feedback and CQI improve quality of care in diabetic patients, although the effect is small and heterogeneous among process and outcomes indicators.

A Diabetes Dashboard and Physician Efficiency and Accuracy in Accessing Data Needed for High-Quality Diabetes Care

PubMed Central

Koopman, Richelle J.; Kochendorfer, Karl M.; Moore, Joi L.; Mehr, David R.; Wakefield, Douglas S.; Yadamsuren, Borchuluun; Coberly, Jared S.; Kruse, Robin L.; Wakefield, Bonnie J.; Belden, Jeffery L.

2011-01-01

PURPOSE We compared use of a new diabetes dashboard screen with use of a conventional approach of viewing multiple electronic health record (EHR) screens to find data needed for ambulatory diabetes care. METHODS We performed a usability study, including a quantitative time study and qualitative analysis of information-seeking behaviors. While being recorded with Morae Recorder software and “think-aloud” interview methods, 10 primary care physicians first searched their EHR for 10 diabetes data elements using a conventional approach for a simulated patient, and then using a new diabetes dashboard for another. We measured time, number of mouse clicks, and accuracy. Two coders analyzed think-aloud and interview data using grounded theory methodology. RESULTS The mean time needed to find all data elements was 5.5 minutes using the conventional approach vs 1.3 minutes using the diabetes dashboard (P <.001). Physicians correctly identified 94% of the data requested using the conventional method, vs 100% with the dashboard (P <.01). The mean number of mouse clicks was 60 for conventional searching vs 3 clicks with the diabetes dashboard (P <.001). A common theme was that in everyday practice, if physicians had to spend too much time searching for data, they would either continue without it or order a test again. CONCLUSIONS Using a patient-specific diabetes dashboard improves both the efficiency and accuracy of acquiring data needed for high-quality diabetes care. Usability analysis tools can provide important insights into the value of optimizing physician use of health information technologies. PMID:21911758

Diabetes quality of care and outpatient utilization associated with electronic patient-provider messaging: a cross-sectional analysis.

PubMed

Harris, Lynne T; Haneuse, Sebastien J; Martin, Diane P; Ralston, James D

2009-07-01

To test the hypothesis that electronic patient-provider messaging is associated with high care quality for diabetes and lower outpatient utilization. We conducted a cross-sectional analysis of electronic patient-provider messaging over a 15-month period between 1 January 2004 and 31 March 2005. The study was set at Group Health Cooperative--a consumer-governed, nonprofit health care system that operates in Washington and Idaho. Participants included all patients aged >or=18 years with a diagnosis of diabetes. In addition to usual care, all patients had the option to use electronic messaging to communicate with their care providers. The primary outcome measures were diabetes-related quality-of-care indicators (A1C, blood pressure, and LDL cholesterol) and outpatient visits (primary care, specialty care, and emergency). Nineteen percent of patients with diabetes used electronic messaging to communicate with their care providers during the study period (n = 2,924) (overall study cohort: 15,427 subjects). In multivariate models, frequent use of electronic messaging was associated with A1C <7% (relative risk [RR] 1.36 [95% CI 1.16-1.58]). Contrary to our hypothesis, frequent use of electronic messaging was also associated with a higher rate of outpatient visits (1.39 [1.26-1.53]). Frequent use of electronic secure messaging is associated with better glycemic control and increased outpatient utilization. Electronic patient-provider communication may represent one strategy to meet the health care needs of this unique population. More research is necessary to assess the effect of electronic messaging on care quality and utilization.

Diabetes care may be improved with Steno Quality Assurance Tool--a self-assessment tool in diabetes management.

PubMed

Bjerre-Christensen, Ulla; Nielsen, Annemette Anker; Binder, Christian; Hansen, Jes B; Eldrup, Ebbe

2014-08-01

To evaluate if improvements in the quality of diabetes care in Indian clinics can be obtained by simple self-surveillance PC-based software. Nineteen Indian diabetes clinics were introduced to the principles of quality assurance (QA), and to a software program, the Steno Quality Assurance Tool (SQAT). Data was entered for an initial 3 months period. Subsequently data were analyzed by the users, who designed plans to improve indicator status and set goals for the upcoming period. A second data entry period followed after 7-9 months. QA data was analyzed from 4487 T2DM patients (baseline) and 4440 (follow-up). The average examination frequency per clinic of the following indicators increased significantly: lipid examination (72-87%) (p=0.007), foot examination (80-94%) (p=0.02), HbA1c investigation (59-77%) (p=0.006), and urine albumin excretion investigation (72-87%) (p=0.006). Outcome parameters also improved significantly: mean (SD) fasting and post prandial BG reduced from 144(16) to 132(16)mg/dl (p=0.02) and 212(24)-195(29)mg/dl (p=0.03), respectively. Systolic BP reduced from 139(6) to 133(4) (p=0.0008)mmHg and diastolic BP from 83(3) to 81(3)mmHg (p=0.002). Quality of diabetes care can be improved by applying SQAT, a QA self-surveillance software that enables documentation of changes in process and outcome indicators. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Quality of care and volume for patients with diabetes mellitus in the primary care setting: A population based retrospective cohort study.

PubMed

Wong, Carlos K H; Fung, Colman S C; Kung, Kenny; Wan, Eric Y F; Yu, Esther Y T; Chan, Anca K C; Lam, Cindy L K

2016-10-01

To examine the association of patient volume with quality of diabetes care in the primary care setting. We analyzed population-based data from Hospital Authority administrative database using a Hong Kong representative sample of 187,031 diabetic patients managed in 74 primary care general outpatient clinics between 04/2011 and 03/2012. We assessed the associations between annual clinic-based patient volume and quality of care in terms of adherence to care criteria of process (HbA1c test, renal function test, full lipid profile, urine protein analysis, diabetic retinopathy screening, and appropriate drug prescription) and clinical outcomes (HbA1c⩽7%, BP⩽130/80mmHg, LDL-C⩽2.6mmol/L) of care criteria, with and without adjustment for patient and clinic characteristics. Patient volume was associated with three of seven process of care criteria; however, when compared to clinics in higher volume quartiles, those in lowest-volume quartile had more odds of HbA1c test (odds ratios (OR): 0.781, 0.655 and 0.646 for quartile from 2 to 4, respectively), renal function test (OR: 0.357, 0.367 and 0.590 for quartile from 2 to 4, respectively), and full lipid profile test (OR: 0.508, 0.612 and 0.793 for quartile from 2 to 4, respectively). There was no significant association between patient volume and the standards of achieving of HbA1c, BP and LDL-C outcome targets. Disparities in volume and quality of diabetes care were observed in public primary care setting. Lower patient volumes at clinic level were associated with greater adherence to three process criteria but a volume-outcome association was not present. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Health System Challenges in Organizing Quality Diabetes Care for Urban Poor in South India

PubMed Central

Bhojani, Upendra; Devedasan, Narayanan; Mishra, Arima; De Henauw, Stefaan; Kolsteren, Patrick; Criel, Bart

2014-01-01

Background Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2. Methods We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis. Result There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity. Conclusions Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic

Health system challenges in organizing quality diabetes care for urban poor in South India.

PubMed

Bhojani, Upendra; Devedasan, Narayanan; Mishra, Arima; De Henauw, Stefaan; Kolsteren, Patrick; Criel, Bart

2014-01-01

Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2. We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis. There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients' medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity. Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.

[Quality of health care for diabetic and hypertensive patients in primary care settings servicing Mexican Seguro Popular].

PubMed

Ortiz-Domínguez, Maki E; Garrido-Latorre, Francisco; Orozco, Ricardo; Pineda-Pérez, Dayana; Rodríguez-Salgado, Marlenne

2011-01-01

To assess health care quality provided to type-2 diabetic and hypertensive patients in primary care settings from the Mexican Ministry of Health and to evaluate whether accredited clinics providing services to the Mexican Seguro Popular performed better in terms of metabolic control of those patients compared to the non-accredited. Cross-sectional study performed on 2008. Previous year clinical measures were obtained from 5 444 diabetic and 5 827 hypertensive patient's clinical records. Adequate metabolic control (glucose <110 mg/dl for diabetes and blood pressure <140/90 mmHg for hypertension) associated factors were assessed by multiple-multilevel logistic regression methods. Patients attending accredited clinics were more likely to be controlled, however, metabolic control was not constant over time of accreditation. Additional efforts are required to monitor accredited clinics' performance in order to maintain both metabolic control and clinical assessment of patients.

Affordable Care Act and Diabetes Mellitus.

PubMed

Shi, Qian; Nellans, Frank P; Shi, Lizheng

2015-12-01

The Affordable Care Act (ACA) has the potential for great impact on U.S. health care, especially for chronic disease patients requiring long-term care and management. The act was designed to improve insurance coverage, health care access, and quality of care for all Americans, which will assist patients with diabetes mellitus in acquiring routine monitoring and diabetes-related complication screening for better health management and outcomes. There is great potential for patients with diabetes to benefit from the new policy mandating health insurance coverage and plan improvement, Medicaid expansion, minimum coverage guarantees, and free preventative care. However, policy variability among states and ACA implementation present challenges to people with diabetes in understanding and optimizing ACA impact. This paper aims to select the most influential components of the ACA as relates to people with diabetes and discuss how the ACA may improve health care for this vulnerable population.

Registry of people with diabetes in three Latin American countries: a suitable approach to evaluate the quality of health care provided to people with type 2 diabetes.

PubMed

Commendatore, V; Dieuzeide, G; Faingold, C; Fuente, G; Luján, D; Aschner, P; Lapertosa, S; Villena Chávez, J; Elgart, J; Gagliardino, J J

2013-12-01

To implement a patient registry and collect data related to the care provided to people with type 2 diabetes in six specialized centers of three Latin American countries, measure the quality of such care using a standardized form (QUALIDIAB) that collects information on different quality of care indicators, and analyze the potential of collecting this information for improving quality of care and conducting clinical research. We collected data on clinical, metabolic and therapeutic indicators, micro- and macrovascular complications, rate of use of diagnostic and therapeutic elements and hospitalization of patients with type 2 diabetes in six diabetes centers, four in Argentina and one each in Colombia and Peru. We analyzed 1157 records from patients with type 2 diabetes (Argentina, 668; Colombia, 220; Peru, 269); 39 records were discarded because of data entry errors or inconsistencies. The data demonstrated frequency performance deficiencies in several procedures, including foot and ocular fundus examination and various cardiovascular screening tests. In contrast, HbA1c and cardiovascular risk factor assessments were performed with a greater frequency than recommended by international guidelines. Management of insulin therapy was sub-optimal, and deficiencies were also noted among diabetes education indicators. Patient registry was successfully implemented in these clinics following an interactive educational program. The data obtained provide useful information as to deficiencies in care and may be used to guide quality of care improvement efforts. © 2013 John Wiley & Sons Ltd.

Benchmarking Is Associated With Improved Quality of Care in Type 2 Diabetes

PubMed Central

Hermans, Michel P.; Elisaf, Moses; Michel, Georges; Muls, Erik; Nobels, Frank; Vandenberghe, Hans; Brotons, Carlos

2013-01-01

OBJECTIVE To assess prospectively the effect of benchmarking on quality of primary care for patients with type 2 diabetes by using three major modifiable cardiovascular risk factors as critical quality indicators. RESEARCH DESIGN AND METHODS Primary care physicians treating patients with type 2 diabetes in six European countries were randomized to give standard care (control group) or standard care with feedback benchmarked against other centers in each country (benchmarking group). In both groups, laboratory tests were performed every 4 months. The primary end point was the percentage of patients achieving preset targets of the critical quality indicators HbA1c, LDL cholesterol, and systolic blood pressure (SBP) after 12 months of follow-up. RESULTS Of 4,027 patients enrolled, 3,996 patients were evaluable and 3,487 completed 12 months of follow-up. Primary end point of HbA1c target was achieved in the benchmarking group by 58.9 vs. 62.1% in the control group (P = 0.398) after 12 months; 40.0 vs. 30.1% patients met the SBP target (P < 0.001); 54.3 vs. 49.7% met the LDL cholesterol target (P = 0.006). Percentages of patients meeting all three targets increased during the study in both groups, with a statistically significant increase observed in the benchmarking group. The percentage of patients achieving all three targets at month 12 was significantly larger in the benchmarking group than in the control group (12.5 vs. 8.1%; P < 0.001). CONCLUSIONS In this prospective, randomized, controlled study, benchmarking was shown to be an effective tool for increasing achievement of critical quality indicators and potentially reducing patient cardiovascular residual risk profile. PMID:23846810

The disease management program for type 2 diabetes in Germany enhances process quality of diabetes care - a follow-up survey of patient's experiences.

PubMed

Schäfer, Ingmar; Küver, Claudia; Gedrose, Benjamin; Hoffmann, Falk; Russ-Thiel, Barbara; Brose, Hans-Peter; van den Bussche, Hendrik; Kaduszkiewicz, Hanna

2010-03-03

In summer 2003 a disease management program (DMP) for type 2 diabetes was introduced on a nationwide basis in Germany. Patient participation and continuity of care within the DMP are important factors to achieve long-term improvements in clinical endpoints. Therefore it is of interest, if patients experience any positive or negative effects of the DMP on their treatment that would support or hamper further participation. The main objective of the study was to find out if the German Disease Management Program (DMP) for type 2 diabetes improves process and outcome quality of medical care for patients in the light of their subjective experiences over a period of one year. Cohort study with a baseline interview and a follow-up after 10.4 +/- 0.64 months. Data on process and outcome measures were collected by telephone interviews with 444 patients enrolled and 494 patients not enrolled in the German DMP for type 2 diabetes. Data were analyzed by multivariate logistic regression analyses. DMP enrolment was significantly associated with a higher process quality of care. At baseline enrolled patients more often reported that they had attended a diabetes education course (OR = 3.4), have > or = 4 contacts/year with the attending physician (OR = 3.3), have at least one annual foot examination (OR = 3.1) and one referral to an ophthalmologist (OR = 3.4) and possess a diabetes passport (OR = 2.4). Except for the annual referral to an ophthalmologist these parameters were also statistically significant at follow-up. In contrast, no differences between enrolled and not enrolled patients were found concerning outcome quality indicators, e.g. self-rated health, Glycated hemoglobin (GHb) and blood pressure. However, 16-36% of the DMP participants reported improvements of body weight and/or GHb and/or blood pressure values due to enrolment - unchanged within one year of follow-up. In the light of patient's experiences the DMP enhances the process quality of medical care for type 2

Patient involvement in diabetes care: experiences in nine diabetes care groups

PubMed Central

de Bruin, Simone R.; Struijs, Jeroen N.; Rijken, Mieke; Nijpels, Giel; Baan, Caroline A.

2015-01-01

Introduction Despite the expected beneficial effects on quality of care, patient involvement in diabetes care groups, which deliver a bundled paid integrated care programme for diabetes type 2, seems to be limited. The aim of this study was to gain insight into levels and methods of patient involvement, into facilitators and barriers, and into the future preferences of care groups and patient representatives. Theory and methods Semi-structured interviews were held with 10 representatives of care groups and 11 representatives of patient advocacy groups. An adapted version of Arnstein's ladder of citizen participation was used to define five levels of patient involvement. Results Patient involvement in care groups was mostly limited to informing and consulting patients. Higher levels, i.e., advising, co-producing and decision-making, were less frequently observed. Care groups and patient representatives perceived largely the same barriers and facilitators and had similar preferences regarding future themes and design of patient involvement. Conclusion Constructive collaboration between diabetes care groups and patient representatives to enhance patient involvement in the future seems viable. Several issues such as the lack of evidence for effectiveness of patient involvement, differences in viewpoints on the role and responsibilities of care groups and perceived barriers need to be addressed. PMID:27118961

What is health-related quality of life? Perspectives from pediatric and adult diabetes care providers

USDA-ARS?s Scientific Manuscript database

While health-related quality of life (HRQOL) is gaining recognition as an important patient-reported outcome in clinical care and research, an understanding of how diabetes care providers define HRQOL or apply it in practice has not been established. The purpose of this study was to characterize the...

Educational disparities in quality of diabetes care in a universal health insurance system: evidence from the 2005 Korea National Health and Nutrition Examination Survey.

PubMed

Do, Young Kyung; Eggleston, Karen N

2011-08-01

To investigate educational disparities in the care process and health outcomes among patients with diabetes in the context of South Korea's universal health insurance system. Bivariate and multiple regression analyses of data from a cross-sectional health survey. A nationally representative and population-based survey, the 2005 Korea National Health and Nutrition Examination Survey. Respondents aged 40 or older who self-reported prior diagnosis with diabetes (n= 1418). Seven measures of the care process and health outcomes, namely (i) receiving medical treatment for diabetes, (ii) ever received diabetes education, (iii) received dilated eye examination in the past year, (iv) received microalbuminuria test in the past year, (v) having activity limitation due to diabetes, (vi) poor self-rated health and (vii) self-rated health on a visual analog scale. Except for receiving medical care for diabetes, overall process quality was low, with only 25% having ever received diabetes education, 39% having received a dilated eye examination in the past year and 51% having received a microalbuminuria test in the past year. Lower education level was associated with both poorer care processes and poorer health outcomes, whereas lower income level was only associated with poorer health outcomes. While South Korea's universal health insurance system may have succeeded in substantially reducing financial barriers related to diabetes care, the quality of diabetes care is low overall and varies by education level. System-level quality improvement efforts are required to address the weaknesses of the health system, thereby mitigating educational disparities in diabetes care quality.

Organizational culture, team climate and diabetes care in small office-based practices.

PubMed

Bosch, Marije; Dijkstra, Rob; Wensing, Michel; van der Weijden, Trudy; Grol, Richard

2008-08-21

Redesigning care has been proposed as a lever for improving chronic illness care. Within primary care, diabetes care is the most widespread example of restructured integrated care. Our goal was to assess to what extent important aspects of restructured care such as multidisciplinary teamwork and different types of organizational culture are associated with high quality diabetes care in small office-based general practices. We conducted cross-sectional analyses of data from 83 health care professionals involved in diabetes care from 30 primary care practices in the Netherlands, with a total of 752 diabetes mellitus type II patients participating in an improvement study. We used self-reported measures of team climate (Team Climate Inventory) and organizational culture (Competing Values Framework), and measures of quality of diabetes care and clinical patient characteristics from medical records and self-report. We conducted multivariate analyses of the relationship between culture, climate and HbA1c, total cholesterol, systolic blood pressure and a sum score on process indicators for the quality of diabetes care, adjusting for potential patient- and practice level confounders and practice-level clustering. A strong group culture was negatively associated to the quality of diabetes care provided to patients (beta = -0.04; p = 0.04), whereas a more 'balanced culture' was positively associated to diabetes care quality (beta = 5.97; p = 0.03). No associations were found between organizational culture, team climate and clinical patient outcomes. Although some significant associations were found between high quality diabetes care in general practice and different organizational cultures, relations were rather marginal. Variation in clinical patient outcomes could not be attributed to organizational culture or teamwork. This study therefore contributes to the discussion about the legitimacy of the widespread idea that aspects of redesigning care such as teamwork and culture

Assessing Impacts on Unplanned Hospitalisations of Care Quality and Access Using a Structural Equation Method: With a Case Study of Diabetes

PubMed Central

Congdon, Peter

2016-01-01

Background: Enhanced quality of care and improved access are central to effective primary care management of long term conditions. However, research evidence is inconclusive in establishing a link between quality of primary care, or access, and adverse outcomes, such as unplanned hospitalisation. Methods: This paper proposes a structural equation model for quality and access as latent variables affecting adverse outcomes, such as unplanned hospitalisations. In a case study application, quality of care (QOC) is defined in relation to diabetes, and the aim is to assess impacts of care quality and access on unplanned hospital admissions for diabetes, while allowing also for socio-economic deprivation, diabetes morbidity, and supply effects. The study involves 90 general practitioner (GP) practices in two London Clinical Commissioning Groups, using clinical quality of care indicators, and patient survey data on perceived access. Results: As a single predictor, quality of care has a significant negative impact on emergency admissions, and this significant effect remains when socio-economic deprivation and morbidity are allowed. In a full structural equation model including access, the probability that QOC negatively impacts on unplanned admissions exceeds 0.9. Furthermore, poor access is linked to deprivation, diminished QOC, and larger list sizes. Conclusions: Using a Bayesian inference methodology, the evidence from the analysis is weighted towards negative impacts of higher primary care quality and improved access on unplanned admissions. The methodology of the paper is potentially applicable to other long term conditions, and relevant when care quality and access cannot be measured directly and are better regarded as latent variables. PMID:27598184

Assessing Impacts on Unplanned Hospitalisations of Care Quality and Access Using a Structural Equation Method: With a Case Study of Diabetes.

PubMed

Congdon, Peter

2016-09-01

Enhanced quality of care and improved access are central to effective primary care management of long term conditions. However, research evidence is inconclusive in establishing a link between quality of primary care, or access, and adverse outcomes, such as unplanned hospitalisation. This paper proposes a structural equation model for quality and access as latent variables affecting adverse outcomes, such as unplanned hospitalisations. In a case study application, quality of care (QOC) is defined in relation to diabetes, and the aim is to assess impacts of care quality and access on unplanned hospital admissions for diabetes, while allowing also for socio-economic deprivation, diabetes morbidity, and supply effects. The study involves 90 general practitioner (GP) practices in two London Clinical Commissioning Groups, using clinical quality of care indicators, and patient survey data on perceived access. As a single predictor, quality of care has a significant negative impact on emergency admissions, and this significant effect remains when socio-economic deprivation and morbidity are allowed. In a full structural equation model including access, the probability that QOC negatively impacts on unplanned admissions exceeds 0.9. Furthermore, poor access is linked to deprivation, diminished QOC, and larger list sizes. Using a Bayesian inference methodology, the evidence from the analysis is weighted towards negative impacts of higher primary care quality and improved access on unplanned admissions. The methodology of the paper is potentially applicable to other long term conditions, and relevant when care quality and access cannot be measured directly and are better regarded as latent variables.

The disease management program for type 2 diabetes in Germany enhances process quality of diabetes care - a follow-up survey of patient's experiences

PubMed Central

2010-01-01

Background In summer 2003 a disease management program (DMP) for type 2 diabetes was introduced on a nationwide basis in Germany. Patient participation and continuity of care within the DMP are important factors to achieve long-term improvements in clinical endpoints. Therefore it is of interest, if patients experience any positive or negative effects of the DMP on their treatment that would support or hamper further participation. The main objective of the study was to find out if the German Disease Management Program (DMP) for type 2 diabetes improves process and outcome quality of medical care for patients in the light of their subjective experiences over a period of one year. Methods Cohort study with a baseline interview and a follow-up after 10.4 ± 0.64 months. Data on process and outcome measures were collected by telephone interviews with 444 patients enrolled and 494 patients not enrolled in the German DMP for type 2 diabetes. Data were analyzed by multivariate logistic regression analyses. Results DMP enrolment was significantly associated with a higher process quality of care. At baseline enrolled patients more often reported that they had attended a diabetes education course (OR = 3.4), have ≥ 4 contacts/year with the attending physician (OR = 3.3), have at least one annual foot examination (OR = 3.1) and one referral to an ophthalmologist (OR = 3.4) and possess a diabetes passport (OR = 2.4). Except for the annual referral to an ophthalmologist these parameters were also statistically significant at follow-up. In contrast, no differences between enrolled and not enrolled patients were found concerning outcome quality indicators, e.g. self-rated health, Glycated hemoglobin (GHb) and blood pressure. However, 16-36% of the DMP participants reported improvements of body weight and/or GHb and/or blood pressure values due to enrolment - unchanged within one year of follow-up. Conclusions In the light of patient's experiences the DMP enhances the process

Quality of Care Improves for Patients with Diabetes in Medicare Shared Savings Accountable Care Organizations: Organizational Characteristics Associated with Performance.

PubMed

Fraze, Taressa K; Lewis, Valerie A; Tierney, Emily; Colla, Carrie H

2017-12-06

Accountable care organizations (ACOs), a primary care-centric delivery and payment model, aim to promote integrated population health, which may improve care for those with chronic conditions such as diabetes. Research has shown that, overall, the ACO model is effective at reducing costs, but there is substantial variation in how effective different types of ACOs are at impacting costs and improving care delivery. This study examines how ACO organizational characteristics - such as composition, staffing, care management, and experiences with health reform - were associated with quality of care delivered to patients with diabetes. Secondary data were analyzed retrospectively to examine Medicare Shared Savings Program (MSSP) ACOs' performance on diabetes metrics in the first 2 years of ACO contracts. Ordinary least squares was used to analyze 162 MSSP ACOs with publicly available performance data and the National Survey of ACOs. ACOs improved performance significantly for patients with diabetes between contract years 1 and 2. In year 1, also having a private payer contract and an increased number of services within the ACO were positively associated with performance, while having a community health center or a hospital were negatively associated with performance. Better performance in year 1 was negatively associated with improved performance in year 2. This study found that ACOs substantively improved diabetes management within initial contract years. ACOs may need different types of support throughout their contracts to ensure continued improvements in performance.

Quality of care for patients with diabetes mellitus type 2 in 'model practices' in Slovenia - first results.

PubMed

Petek, Davorina; Mlakar, Mitja

2016-09-01

A new organisation at the primary level, called model practices, introduces a 0.5 full-time equivalent nurse practitioner as a regular member of the team. Nurse practitioners are in charge of registers of chronic patients, and implement an active approach into medical care. Selected quality indicators define the quality of management. The majority of studies confirm the effectiveness of the extended team in the quality of care, which is similar or improved when compared to care performed by the physician alone. The aim of the study is to compare the quality of management of patients with diabetes mellitus type 2 before and after the introduction of model practices. A cohort retrospective study was based on medical records from three practices. Process quality indicators, such as regularity of HbA1c measurement, blood pressure measurement, foot exam, referral to eye exam, performance of yearly laboratory tests and HbA1c level before and after the introduction of model practices were compared. The final sample consisted of 132 patients, whose diabetes care was exclusively performed at the primary care level. The process of care has significantly improved after the delivery of model practices. The most outstanding is the increase of foot exam and HbA1c testing. We could not prove better glycaemic control (p>0.1). Nevertheless, the proposed benchmark for the suggested quality process and outcome indicators were mostly exceeded in this cohort. The introduction of a nurse into the team improves the process quality of care. Benchmarks for quality indicators are obtainable. Better outcomes of care need further confirmation.

A disease management programme for patients with diabetes mellitus is associated with improved quality of care within existing budgets.

PubMed

Steuten, L M G; Vrijhoef, H J M; Landewé-Cleuren, S; Schaper, N; Van Merode, G G; Spreeuwenberg, C

2007-10-01

To assess the impact of a disease management programme for patients with diabetes mellitus (Type 1 and Type 2) on cost-effectiveness, quality of life and patient self-management. By organizing care in accordance with the principles of disease management, it is aimed to increase quality of care within existing budgets. Single-group, pre-post design with 2-year follow-up in 473 patients. Substantial significant improvements in glycaemic control, health-related quality of life (HRQL) and patient self-management were found. No significant changes were detected in total costs of care. The probability that the disease management programme is cost-effective compared with usual care amounts to 74%, expressed in an average saving of 117 per additional life year at 5% improved HRQL. Introduction of a disease management programme for patients with diabetes is associated with improved intermediate outcomes within existing budgets. Further research should focus on long-term cost-effectiveness, including diabetic complications and mortality, in a controlled setting or by using decision-analytic modelling techniques.

Quality of diabetes care predicts the development of cardiovascular events: results of the AMD-QUASAR study.

PubMed

Rossi, Maria C E; Lucisano, Giuseppe; Comaschi, Marco; Coscelli, Carlo; Cucinotta, Domenico; Di Blasi, Patrizia; Bader, Giovanni; Pellegrini, Fabio; Valentini, Umberto; Vespasiani, Giacomo; Nicolucci, Antonio

2011-02-01

The QUASAR (Quality Assessment Score and Cardiovascular Outcomes in Italian Diabetes Patients) study aimed to assess whether a quality-of-care summary score predicted the development of cardiovascular (CV) events in patients with type 2 diabetes. In 67 diabetes clinics, data on randomly selected patients were extracted from electronic medical records. The score was calculated using process and outcome indicators based on monitoring, targets, and treatment of A1C, blood pressure, LDL cholesterol, and microalbuminuria. The score ranged from 0 to 40. Overall, 5,181 patients were analyzed; 477 (9.2%) patients developed a CV event after a median follow-up of 28 months. The incidence rate (per 1,000 person-years) of CV events was 62.4 in patients with a score of <15, 41.0 in those with a score between 20 and 25 and 36.7 in those with a score of >25. Multilevel analysis, adjusted for clustering and case-mix, showed that the risk to develop a new CV event was 84% higher in patients with a score of <15 (incidence rate ratio [IRR] = 1.84; 95% confidence interval [CI] 1.29-2.62) and 17% higher in those with a score between 15 and 25 (IRR = 1.17; 95% CI 0.93-1.49) compared with those with a score of >25. Mean quality score varied across centers from 16.5 ± 7.5 to 29.1 ± 6.3. When the score was tested as the dependent variable, it emerged that 18% of the variance in the score could be attributed to setting characteristics. Our study documented a close relationship between quality of diabetes care and long-term outcomes. A simple score can be used to monitor quality of care and compare the performance of different centers/physicians.

Quality of Diabetes Care Predicts the Development of Cardiovascular Events: Results of the AMD-QUASAR Study

PubMed Central

Rossi, Maria C.E.; Lucisano, Giuseppe; Comaschi, Marco; Coscelli, Carlo; Cucinotta, Domenico; Di Blasi, Patrizia; Bader, Giovanni; Pellegrini, Fabio; Valentini, Umberto; Vespasiani, Giacomo; Nicolucci, Antonio

2011-01-01

OBJECTIVE The QUASAR (Quality Assessment Score and Cardiovascular Outcomes in Italian Diabetes Patients) study aimed to assess whether a quality-of-care summary score predicted the development of cardiovascular (CV) events in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS In 67 diabetes clinics, data on randomly selected patients were extracted from electronic medical records. The score was calculated using process and outcome indicators based on monitoring, targets, and treatment of A1C, blood pressure, LDL cholesterol, and microalbuminuria. The score ranged from 0 to 40. RESULTS Overall, 5,181 patients were analyzed; 477 (9.2%) patients developed a CV event after a median follow-up of 28 months. The incidence rate (per 1,000 person-years) of CV events was 62.4 in patients with a score of <15, 41.0 in those with a score between 20 and 25 and 36.7 in those with a score of >25. Multilevel analysis, adjusted for clustering and case-mix, showed that the risk to develop a new CV event was 84% higher in patients with a score of <15 (incidence rate ratio [IRR] = 1.84; 95% confidence interval [CI] 1.29–2.62) and 17% higher in those with a score between 15 and 25 (IRR = 1.17; 95% CI 0.93–1.49) compared with those with a score of >25. Mean quality score varied across centers from 16.5 ± 7.5 to 29.1 ± 6.3. When the score was tested as the dependent variable, it emerged that 18% of the variance in the score could be attributed to setting characteristics. CONCLUSIONS Our study documented a close relationship between quality of diabetes care and long-term outcomes. A simple score can be used to monitor quality of care and compare the performance of different centers/physicians. PMID:21270192

Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers.

PubMed

Leung, Lucinda B; Vargas-Bustamante, Arturo; Martinez, Ana E; Chen, Xiao; Rodriguez, Hector P

2018-02-01

To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference. Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053). We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups. After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients. Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients. © Health Research and Educational Trust.

Quality of previous diabetes care among patients receiving services at ophthalmology hospitals in Mexico.

PubMed

Rodríguez-Saldana, Joel; Rosales-Campos, Andrea C; Rangel León, Carmen B; Vázquez-Rodríguez, Laura I; Martínez-Castro, Francisco; Piette, John D

2010-12-01

To survey a large sample of type 2 diabetes mellitus (T2DM) patients in Mexico City to determine if patient experience, access to basic services, treatment, and outcomes differed between those with social security coverage and those without. From 2001-2007 a total of 1 000 individuals with T2DM were surveyed in outpatient clinics of the three largest public ophthalmology hospitals in Mexico City. Patients reported information about their health status and receipt of basic diabetes services, such as laboratory glycemic monitoring and diabetes education. Rates were compared between those with (n = 461) and without (n = 539) social security. Almost half of the patients (46%) in these public facilities were social security patients that were unable to access other services and had to pay out-of-pocket for care. Half of respondents were originally identified as potentially diabetic based on symptom complaints (51%), including 11% with visual impairment. Most patients (87.9%) reported that their glycemic level was being monitored exclusively via fasting blood glucose testing or random capillary blood glucose tests; only 5.3% reported ever having a glycated hemoglobin test. While nearly all respondents reported an individual physician encounter ever, only 39% reported ever receiving nutrition counseling and only 21% reported attending one or more sessions of diabetes education in their lifetime. Processes of care and outcomes were no different in patients with and those without social security coverage. In Mexico, the quality of diabetes care is poor. Despite receiving social security, many patients still have to pay out-of-pocket to access needed care. Without policy changes that address these barriers to comprehensive diabetes management, scientific achievements in diagnosis and pharmacotherapy will have limited impact.

Care of Patients with Diabetic Foot Disease in Oman.

PubMed

Al-Busaidi, Ibrahim S; Abdulhadi, Nadia N; Coppell, Kirsten J

2016-08-01

Diabetes mellitus is a major public health challenge and causes substantial morbidity and mortality worldwide. Diabetic foot disease is one of the most debilitating and costly complications of diabetes. While simple preventative foot care measures can reduce the risk of lower limb ulcerations and subsequent amputations by up to 85%, they are not always implemented. In Oman, foot care for patients with diabetes is mainly provided in primary and secondary care settings. Among all lower limb amputations performed in public hospitals in Oman between 2002-2013, 47.3% were performed on patients with diabetes. The quality of foot care among patients with diabetes in Oman has not been evaluated and unidentified gaps in care may exist. This article highlights challenges in the provision of adequate foot care to Omani patients with diabetes. It concludes with suggested strategies for an integrated national diabetic foot care programme in Oman.

Care of Patients with Diabetic Foot Disease in Oman

PubMed Central

Al-Busaidi, Ibrahim S.; Abdulhadi, Nadia N.; Coppell, Kirsten J.

2016-01-01

Diabetes mellitus is a major public health challenge and causes substantial morbidity and mortality worldwide. Diabetic foot disease is one of the most debilitating and costly complications of diabetes. While simple preventative foot care measures can reduce the risk of lower limb ulcerations and subsequent amputations by up to 85%, they are not always implemented. In Oman, foot care for patients with diabetes is mainly provided in primary and secondary care settings. Among all lower limb amputations performed in public hospitals in Oman between 2002–2013, 47.3% were performed on patients with diabetes. The quality of foot care among patients with diabetes in Oman has not been evaluated and unidentified gaps in care may exist. This article highlights challenges in the provision of adequate foot care to Omani patients with diabetes. It concludes with suggested strategies for an integrated national diabetic foot care programme in Oman. PMID:27606104

Evaluation of a community diabetes initiative: Integrating diabetes care.

PubMed

Walsh, Jason Leo; Harris, Benjamin Howell Lole; Roberts, Aled Wyn

2015-06-01

To evaluate the impact of a community diabetes initiative, aiming to improve the efficiency of type 2 diabetes (T2DM) care within the Cardiff and Vale Health Board. In 2012, a community diabetes initiative was introduced in Cardiff and Vale. Ten National Health Service (NHS) consultant diabetologists and three nurse specialists supported 69 general practices in this region. Here we evaluate the impact of this initiative by assessing the number and quality of secondary care diabetes clinic referrals before (2011-2012) and after implementation (2013-2014). Referrals pre and post initiative were audited against Cardiff and Vale T2DM referral guidelines in two 6-month periods. In the 6-months prior to the initiative, 108 referrals were received, 78 of which were in line with local guidance. Approximately one year after embarking on the diabetes initiative (2013-2014) there was a 31% reduction (p<0.01) in the total number of T2DM clinic referrals and a 57% reduction (p<0.01) in referrals outside the guidelines. A decrease in referrals was not seen in the practice noted not to engage with the initiative. The community diabetes initiative intervention has significantly improved the appropriateness of T2DM referrals from GP practices engaged with the initiative. As a result we advocate a move towards integrated diabetes care within the community. Copyright © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

The impact of financial barriers on access to care, quality of care and vascular morbidity among patients with diabetes and coronary heart disease.

PubMed

Parikh, Puja B; Yang, Jie; Leigh, Steven; Dorjee, Kunchok; Parikh, Roopali; Sakellarios, Nicholas; Meng, Hongdao; Brown, David L

2014-01-01

The prevalence and consequences of financial barriers to health care among patients with multiple chronic diseases are poorly understood. We sought to assess the prevalence of self-reported financial barriers to health care among individuals with diabetes and coronary heart disease (CHD) and to determine their association with access to care, quality of care and clinical outcomes. The 2007 Centers for Disease Control Behavioral Risk Factor Surveillance Survey. Diabetic patients with CHD. Financial barriers to health care were defined by a self-reported time in the past 12 months when the respondent needed to see a doctor but could not because of cost. The primary clinical outcome was vascular morbidity—a composite of stroke, retinopathy, nonhealing foot sores or bilateral foot amputations. Among the 11,274 diabetics with CHD, 1,541 (13.7 %) reported financial barriers to health care. Compared to individuals without financial barriers, those with financial barriers had significantly reduced rates of medical assessments within the past 2 years, hemoglobin (Hgb) A1C measurements in the past year, cholesterol measurements at any time, eye and foot examinations within the past year, diabetic education, antihypertensive treatment, aspirin use and a higher prevalence of vascular morbidity. In multivariable analyses, financial barriers to health care were independently associated with reduced odds of medical checkups (Odds Ratio [OR], 0.61; 95 % Confidence Intervals [CI], 0.55–0.67), Hgb A1C measurement (OR, 0.85; 95 % CI, 0.77–0.94), cholesterol measurement (OR, 0.76; 95 % CI, 0.67–0.86), eye (OR, 0.85; 95 % CI, 0.79–0.92) and foot (OR, 0.92; 95 % CI, 0.84–1.00) examinations, diabetic education (OR, 0.93; 95 % CI, 0.87–0.99), aspirin use (OR, 0.88; 95 % CI, 0.81–0.96) and increased odds of vascular morbidity (OR, 1.23; 95 % CI, 1.14–1.33). In diabetic adults with CHD, financial barriers to health care were associated with impaired access to medical care

[Efficacy of the strategy to improve the quality indicators of Diabetes Mellitus 2 Care Process in Advanced Diabetes Centre Macarena].

PubMed

Vélez, Juan Manuel; García, Rosa; Pina, Enrique; Morales, Cristóbal; Escalera, Carmen; Ortega, Antonio; Poyatos, Blas; Carrasco, Dolores; Prieto, Jesús; Ángeles Eslava, M; Antonio Corrales, J; Barón, María O; Llano, Mercedes; Ruiz, Francisco; Sánchez, Romualdo; Victorino Pino, Manuel; Luisa Redondo, M; Castellanos, Antonio; Mayoral, Eduardo

2018-02-21

The assessment of the Diabetes Mellitus 2 Care Process (PAI-DM2) through the assessment tool for the chronic illness' care models (IEMAC-Diabetes) allows the design of health interventions for the improvement of medical care. Analysing the quality of healthcare provided to DM2 patients. Quasiexperimental study before and after intervention with a not randomised control group. Health care district of primary care Sevilla. 12 groups of ascribed patients, 5 Primary Care Healthcenter, chosen in a discretionary way. Physicians and nurses from the 12 intervention groups took part in a training program, including an external rotation in the Diabetes Daycare Hospital. Number of included patients, glycated hemoglobin, feet exploration (FE), and ocular fundus (OF). 1,475 DM-2 patients were analysed. The proportion of included patients per group was 8.5%, 45.5% were women. At the beginning of the study, the rate of patients with HbA1c<7% were 38.9% in 2013 against 47.7% in 2014 and 40.2% in 2016; 33% of the patients had an OF in 2013 against 41.77% in 2014; 51.6% of patients had an EF against 54.7% in 2014. After the intervention, statistically significant differences were reached in HbA1c (p=0.01) and retinography requested (p=0.01). IEMAC-Diabetes allows spotting improvement areas in the PAI-DM2. The absence of statistically significant differences may be the result of contamination in the sample and/or Hawthorne effect. Copyright © 2017 The Authors. Publicado por Elsevier España, S.L.U. All rights reserved.

Costs associated with data collection and reporting for diabetes quality improvement in primary care practices: a report from SNOCAP-USA.

PubMed

West, David R; Radcliff, Tiffany A; Brown, Tiffany; Cote, Murray J; Smith, Peter C; Dickinson, W Perry

2012-01-01

Information about the costs and experiences of collecting and reporting quality measure data are vital for practices deciding whether to adopt new quality improvement initiatives or monitor existing initiatives. Six primary care practices from Colorado's Improving Performance in Practice program participated. We conducted structured key informant interviews with Improving Performance in Practice coaches and practice managers, clinicians, and staff and directly observed practices. Practices had 3 to 7 clinicians and 75 to 300 patients with diabetes, half had electronic health records, and half were members of an independent practice association. The estimated per-practice cost of implementation for the data collection and reporting for the diabetes quality improvement program was approximately $15,552 per practice (about $6.23 per diabetic patient per month). The first-year maintenance cost for this effort was approximately $9,553 per practice ($3.83 per diabetic patient per month). The cost of implementing and maintaining a diabetes quality improvement effort that incorporates formal data collection, data management, and reporting is significant and quantifiable. Policymakers must become aware of the financial and cultural impact on primary care practices when considering value-based purchasing initiatives.

Health-Related Quality of Life in Primary Care: Which Aspects Matter in Multimorbid Patients with Type 2 Diabetes Mellitus in a Community Setting?

PubMed

Kamradt, Martina; Krisam, Johannes; Kiel, Marion; Qreini, Markus; Besier, Werner; Szecsenyi, Joachim; Ose, Dominik

2017-01-01

Knowledge about predictors of health-related quality of life for multimorbid patients with type 2 diabetes mellitus in primary care could help to improve quality and patient-centeredness of care in this specific group of patients. Thus, the aim of this study was to investigate the impact of several patient characteristics on health-related quality of life of multimorbid patients with type 2 diabetes mellitus in a community setting. A cross-sectional study with 32 primary care practice teams in Mannheim, Germany, and randomly selected multimorbid patients with type 2 diabetes mellitus (N = 495) was conducted. In order to analyze associations of various patient characteristics with health-related quality of life (EQ-5D index) a multilevel analysis was applied. After excluding patients with missing data, the cohort consisted of 404 eligible patients. The final multilevel model highlighted six out of 14 explanatory patient variables which were significantly associated with health-related quality of life: female gender (r = -0.0494; p = .0261), school education of nine years or less (r = -0.0609; p = .0006), (physical) mobility restrictions (r = -0.1074; p = .0003), presence of chronic pain (r = -0.0916; p = .0004), diabetes-related distress (r = -0.0133; p < .0001), and BMI (r = -0.0047; p = .0045). The findings of this study suggest that increased diabetes-related distress, chronic pain, restrictions in (physical) mobility, female gender, as well as lower education and, increased BMI have a noteworthy impact on health-related quality of life in multimorbid patients with type 2 diabetes mellitus seen in primary care practices in a community setting. The highlighted aspects should gain much more attention when treating multimorbid patients with type 2 diabetes mellitus.

Coaching of physicians by RNs to improve diabetes care.

PubMed

Frederick, Mary L; Johnson, Pamela Jo; Duffee, Janelle; McCarthy, Bruce D

2013-01-01

The purpose of this study is to describe preliminary results of an innovative quality improvement intervention focused on improving physician practice patterns in diabetes care via Coaching Physicians by RN certified diabetes educators (CDEs), a program called "CPR for Diabetes Care." METHODS The program identified primary care physicians with optimal diabetes control rates below the system aggregate (n = 195). Physicians with the lowest rates (n = 74) were targeted for comprehensive intervention. All other low-performing physicians practicing in the same clinic system (n = 121) comprised the comparison group. Data were obtained from electronic diabetes registries for 2007 and 2008. Each physician had a set of measures from 2 points in time. Measures included optimal diabetes scores and the 5 component measures of the optimal diabetes care bundle (A1C <7, low-density lipoprotein cholesterol <100, blood pressure <130/80, aspirin use if older than 40, and no tobacco use). T tests and difference-in-difference models were used to examine changes over time. Optimal diabetes scores increased 11.7 points (from 14.7% to 26.4%) for intervention physicians and 4.0 points (from 29.7% to 32.9%) for comparison physicians. The improvement was greater for the intervention group. The greatest component improvements were in control of blood pressure and cholesterol. CONCLUSIONS Coaching low-performing physicians dramatically improved the proportion of diabetes patients with optimal diabetes control. The CPR for Diabetes Care program represents an innovative and effective way to address the long-standing problem of disseminating and sustaining quality improvement efforts by focusing on low-performing physicians.

Quality of care for patients with diabetes mellitus type 2 in ‘model practices’ in Slovenia – first results

PubMed Central

Mlakar, Mitja

2016-01-01

Abstract Background A new organisation at the primary level, called model practices, introduces a 0.5 full-time equivalent nurse practitioner as a regular member of the team. Nurse practitioners are in charge of registers of chronic patients, and implement an active approach into medical care. Selected quality indicators define the quality of management. The majority of studies confirm the effectiveness of the extended team in the quality of care, which is similar or improved when compared to care performed by the physician alone. The aim of the study is to compare the quality of management of patients with diabetes mellitus type 2 before and after the introduction of model practices. Methods A cohort retrospective study was based on medical records from three practices. Process quality indicators, such as regularity of HbA1c measurement, blood pressure measurement, foot exam, referral to eye exam, performance of yearly laboratory tests and HbA1c level before and after the introduction of model practices were compared. Results The final sample consisted of 132 patients, whose diabetes care was exclusively performed at the primary care level. The process of care has significantly improved after the delivery of model practices. The most outstanding is the increase of foot exam and HbA1c testing. We could not prove better glycaemic control (p>0.1). Nevertheless, the proposed benchmark for the suggested quality process and outcome indicators were mostly exceeded in this cohort. Conclusion The introduction of a nurse into the team improves the process quality of care. Benchmarks for quality indicators are obtainable. Better outcomes of care need further confirmation. PMID:27703537

Relational Climate and Health Care Costs: Evidence From Diabetes Care.

PubMed

Soley-Bori, Marina; Stefos, Theodore; Burgess, James F; Benzer, Justin K

2018-01-01

Quality of care worries and rising costs have resulted in a widespread interest in enhancing the efficiency of health care delivery. One area of increasing interest is in promoting teamwork as a way of coordinating efforts to reduce costs and improve quality, and identifying the characteristics of the work environment that support teamwork. Relational climate is a measure of the work environment that captures shared employee perceptions of teamwork, conflict resolution, and diversity acceptance. Previous research has found a positive association between relational climate and quality of care, yet its relationship with costs remains unexplored. We examined the influence of primary care relational climate on health care costs incurred by diabetic patients at the U.S. Department of Veterans Affairs between 2008 and 2012. We found that better relational climate is significantly related to lower costs. Clinics with the strongest relational climate saved $334 in outpatient costs per patient compared with facilities with the weakest score in 2010. The total outpatient cost saving if all clinics achieved the top 5% relational climate score was $20 million. Relational climate may contribute to lower costs by enhancing diabetic treatment work processes, especially in outpatient settings.

Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients

PubMed Central

2012-01-01

Background Type 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework. Method/design For evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework. Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to

Evaluation of the quality of care of a multi-disciplinary risk factor assessment and management programme (RAMP) for diabetic patients.

PubMed

Fung, Colman S C; Chin, Weng Yee; Dai, Daisy S K; Kwok, Ruby L P; Tsui, Eva L H; Wan, Yuk Fai; Wong, Wendy; Wong, Carlos K H; Fong, Daniel Y T; Lam, Cindy L K

2012-12-05

Type 2 Diabetes Mellitus (DM) is a common chronic disease associated with multiple clinical complications. Management guidelines have been established which recommend a risk-stratified approach to managing these patients in primary care. This study aims to evaluate the quality of care (QOC) and effectiveness of a multi-disciplinary risk assessment and management programme (RAMP) for type 2 diabetic patients attending government-funded primary care clinics in Hong Kong. The evaluation will be conducted using a structured and comprehensive evidence-based evaluation framework. For evaluation of the quality of care, a longitudinal study will be conducted using the Action Learning and Audit Spiral methodologies to measure whether the pre-set target standards for criteria related to the structure and process of care are achieved. Each participating clinic will be invited to complete a Structure of Care Questionnaire evaluating pre-defined indicators which reflect the setting in which care is delivered, while process of care will be evaluated against the pre-defined indicators in the evaluation framework.Effectiveness of the programme will be evaluated in terms of clinical outcomes, service utilization outcomes, and patient-reported outcomes. A cohort study will be conducted on all eligible diabetic patients who have enrolled into RAMP for more than one year to compare their clinical and public service utilization outcomes of RAMP participants and non-participants. Clinical outcome measures will include HbA1c, blood pressure (both systolic and diastolic), lipids (low-density lipoprotein cholesterol) and future cardiovascular diseases risk prediction; and public health service utilization rate will include general and specialist outpatient, emergency department attendances, and hospital admissions annually within 5 years. For patient-reported outcomes, a total of 550 participants and another 550 non-participants will be followed by telephone to monitor quality of life

Diabetes Care Program of Nova Scotia: Celebrating 25 Years of Improving Diabetes Care in Nova Scotia.

PubMed

Payne, Jennifer I; Dunbar, Margaret J; Talbot, Pamela; Tan, Meng H

2018-06-01

The Diabetes Care Program of Nova Scotia (DCPNS)'s mission is "to improve, through leadership and partnerships, the health of Nova Scotians living with, affected by, or at risk of developing diabetes." Working together with local, provincial and national partners, the DCPNS has improved and standardized diabetes care in Nova Scotia over the past 25 years by developing and deploying a resourceful and collaborative program model. This article describes the model and highlights its key achievements. With balanced representation from frontline providers through to senior decision makers in health care, the DCPNS works across the age continuum, supporting the implementation of national clinical practice guidelines and, when necessary, developing provincial guidelines to meet local needs. The development and implementation of standardized documentation and data collection tools in all diabetes centres created a robust opportunity for the development and expansion of the DCPNS registry. This registry provides useful clinical and statistical information to staff, providers within the circle of care, management and senior leadership. Data are used to support individual care, program planning, quality improvement and business planning at both the local and the provincial levels. The DCPNS supports the sharing of new knowledge and advances through continuous education for providers. The DCPNS's ability to engage diabetes educators and key physician champions has ensured balanced perspectives in the creation of tools and resources that can be effective in real-world practice. The DCPNS has evolved to become an illustrative example of the chronic care model in action. Copyright © 2017 Diabetes Canada. Published by Elsevier Inc. All rights reserved.

The Impact of Patient-Centered Medical Homes on Quality of Care and Medication Adherence in Patients with Diabetes Mellitus.

PubMed

An, JaeJin

2016-11-01

Current evidence suggests that patient-centered medical homes (PCMHs) potentially increase overall quality of disease management, including preventive care. However, there are mixed findings regarding quality of diabetes care, and little evidence exists with respect to the effect of PCMHs on medication adherence in patients with diabetes. To investigate associations between PCMHs and process measures of diabetes care, as well as adherence to oral hypoglycemic agents (OHAs) in patients with diabetes in a nationally representative U.S. Using the 2009-2013 longitudinal data files from the Medical Expenditure Panel Survey, adult diabetes patients were identified. Patients whose usual sources of care have all PCMH features at baseline (i.e., enhanced access after hours and online, shared decision making, and enhanced patient engagement) were categorized as the PCMH group, which was compared with patients without PCMH features. Process measures of diabetes care included ≥ 2 hemoglobin A1c tests and ≥ 1 cholesterol test, foot examination, dilated eye examination, and flu vaccination during 1 year of follow-up. Medication possession ratio (MPR) during follow-up was calculated for patients with OHAs without any insulin use, with MPR ≥ 80% considered to be adherent to OHAs. Univariate and multivariate regression models considering sampling strata and weights were used to examine the association between the PCMH and study outcomes. A total of 3,334 patients with diabetes was identified, representing 61 million U.S. lives. The mean (SE) age was 61.6 (0.3) years, and 52.4% of patients were female. The mean (SE) years of having diabetes was 12.0 (0.2) years. Approximately 11.4% of the patients were categorized as the PCMH group at baseline, and only 3.6% of those patients remained in the PCMH group for 2 years. Of the diabetic patients identified, only 26.9% met all of the diabetes care process measure criteria defined in this study. A higher proportion of patients met

Population management, systems-based practice, and planned chronic illness care: integrating disease management competencies into primary care to improve composite diabetes quality measures.

PubMed

Kimura, Joe; DaSilva, Karen; Marshall, Richard

2008-02-01

The increasing prevalence of chronic illnesses in the United States requires a fundamental redesign of the primary care delivery system's structure and processes in order to meet the changing needs and expectations of patients. Population management, systems-based practice, and planned chronic illness care are 3 potential processes that can be integrated into primary care and are compatible with the Chronic Care Model. In 2003, Harvard Vanguard Medical Associates, a multispecialty ambulatory physician group practice based in Boston, Massachusetts, began implementing all 3 processes across its primary care practices. From 2004 to 2006, the overall diabetes composite quality measures improved from 51% to 58% for screening (HgA1c x 2, low-density lipoprotein, blood pressure in 12 months) and from 13% to 17% for intermediate outcomes (HgA1c care and the positive impact of those changes on overall diabetes quality of care.

Clinical Diabetes Centers of Excellence: A Model for Future Adult Diabetes Care.

PubMed

Draznin, Boris; Kahn, Peter A; Wagner, Nicole; Hirsch, Irl B; Korytkowski, Mary; Harlan, David M; McDonnell, Marie E; Gabbay, Robert A

2018-03-01

Although diabetes research centers are well defined by National Institutes of Health, there is no clear definition for clinical Diabetes Centers of Excellence (DCOEs). There are multiple clinical diabetes centers across the United States, some established with philanthropic funding; however, it is not clear what defines a DCOE from a clinical perspective and what the future will be for these centers. In this Perspective we propose a framework to guide advancement for DCOEs. With the shift toward value-based purchasing and reimbursement and away from fee for service, defining the procedures for broader implementation of DCOEs as a way to improve population health and patient care experience (including quality and satisfaction) and reduce health care costs becomes critically important. It is prudent to implement new financial systems for compensating diabetes care that may not be provided by fiscally constrained private and academic medical centers. We envision that future clinical DCOEs would be composed of a well-defined infrastructure and six domains or pillars serving as the general guiding principles for developing expertise in diabetes care that can be readily demonstrated to stakeholders, including health care providers, patients, payers, and government agencies.

Depression, self-esteem, diabetes care and self-care behaviors among middle-aged and older Mexicans.

PubMed

Rivera-Hernandez, Maricruz

2014-07-01

Examine the associations of depression and self-esteem on self-care activities and care received among Mexicans with diabetes. Using data from the Mexican Nutrition and Health Survey 2012, logistic regression models were fit to test the associations between each self-care activity and diabetes care, and self-esteem and depression. People with low self-esteem were less likely to follow a diet, but no other associations were found. Contrary to what was expected, there were no relationships between depression and quality of care received or self-care behaviors. Current findings support the importance of looking at mental health and emotional state among older adults with diabetes. Future studies should explore the relationship between different psychological barriers to proper diabetes management. Published by Elsevier Ireland Ltd.

Depression, self-esteem, diabetes care and self-care behaviors among middle-aged and older Mexicans☆

PubMed Central

Rivera-Hernandez, Maricruz

2016-01-01

Aims Examine the associations of depression and self-esteem on self-care activities and care received among Mexicans with diabetes. Methods Using data from the Mexican Nutrition and Health Survey 2012, logistic regression models were fit to test the associations between each self-care activity and diabetes care, and self-esteem and depression. Results People with low self-esteem were less likely to follow a diet, but no other associations were found. Contrary to what was expected, there were no relationships between depression and quality of care received or self-care behaviors. Conclusion Current findings support the importance of looking at mental health and emotional state among older adults with diabetes. Future studies should explore the relationship between different psychological barriers to proper diabetes management. PMID:24846446

A long-term quality-of-care score for predicting the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus.

PubMed

Li, Pi-I; Wang, Jian-Nan; Guo, How-Ran

2018-05-01

The aim of this study was to develop a long-term quality-of-care score to predict the occurrence of macrovascular diseases in patients with type 2 diabetes mellitus, on the basis of the hypothesis that good quality of care can reduce the risk of macrovascular complications. Using Taiwan's Longitudinal Cohort of Diabetes Patients Database and the medical records in a medical center, we identified the incident patients diagnosed with type 2 diabetes during 1999-2003 and followed them until 2011. A summary score (from 0 to 8) was calculated according to process indicators (frequencies of HbA1 c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA1 c ), and the co-morbidity of hypertension. We used Cox regression models to evaluate the association between the score and the incidence of macrovascular complications. Of the 4275 patients enrolled, 1928 developed macrovascular complication events after a mean follow-up period of 8.2 years. Compared to the risk of developing a macrovascular disease event in patients with scores ≤1, the risk was 64% lower in those with quality-of-care scores ≥5 (adjusted hazard ratio = 0.36; 95% confidence interval: 0.28-0.45). Good quality of care can reduce the risk of macrovascular diseases in patients with type 2 diabetes. The score developed in this study had a significant association with the risk of macrovascular complications and thus can be applied to guiding the care for these patients. Copyright © 2018 Elsevier B.V. All rights reserved.

Changes in quality of care and costs induced by implementation of a diabetes program in a social security entity of Argentina.

PubMed

González, Lorena; Elgart, Jorge F; Calvo, Héctor; Gagliardino, Juan J

2013-01-01

To measure the impact of a diabetes and cardiovascular risk factors program implemented in a social security institution upon short- and long-term clinical/metabolic outcomes and costs of care. Observational longitudinal cohort analysis of clinical/metabolic data and resource use of 300 adult male and female program participants with diabetes before (baseline) and 1 and 3 years after implementation of the program. Data were obtained from clinical records (Qualidiab) and the administration's database. The implementation of the program in "real world" conditions resulted in an immediate and sustainable improvement of the quality of care provided to people with diabetes incorporated therein. We also recorded a more appropriate oral therapy prescription for hyperglycemia and cardiovascular risk factors (CVRFs), as well as a decrease of events related to chronic complications. This improvement was associated with an increased use of diagnostic and therapeutic resources, particularly those related to pharmacy prescriptions, not specifically used for the control of hyperglycemia and other CVRFs. The implementation of a diabetes program in real-world conditions results in a significant short- and long-term improvement of the quality of care provided to people with diabetes and other CVRFs, but simultaneously increased the use of resources and the cost of diagnostic and therapeutic practices. Since controlled studies have shown improvement in quality of care without increasing costs, our results suggest the need to include management-control strategies in these programs for appropriate medical and administrative feedback to ensure the simultaneous improvement of clinical outcomes and optimization of the use of resources.

The effect of feedback to general practitioners on quality of care for people with type 2 diabetes. A systematic review of the literature

PubMed Central

Guldberg, Trine Lignell; Lauritzen, Torsten; Kristensen, Jette Kolding; Vedsted, Peter

2009-01-01

Background There have been numerous efforts to improve and assure the quality of treatment and follow-up of people with Type 2 diabetes (PT2D) in general practice. Facilitated by the increasing usability and validity of guidelines, indicators and databases, feedback on diabetes care is a promising tool in this aspect. Our goal was to assess the effect of feedback to general practitioners (GPs) on the quality of care for PT2D based on the available literature. Methods Systematic review searches were conducted using October 2008 updates of Medline (Pubmed), Cochrane library and Embase databases. Additional searches in reference lists and related articles were conducted. Papers were included if published in English, performed as randomized controlled trials, studying diabetes, having general practice as setting and using feedback to GPs on diabetes care. The papers were assessed according to predefined criteria. Results Ten studies complied with the inclusion criteria. Feedback improved the care for PT2D, particularly process outcomes such as foot exams, eye exams and Hba1c measurements. Clinical outcomes like lowering of blood pressure, Hba1c and cholesterol levels were seen in few studies. Many process and outcome measures did not improve, while none deteriorated. Meta analysis was unfeasible due to heterogeneity of the studies included. Two studies used electronic feedback. Conclusion Based on this review, feedback seems a promising tool for quality improvement in diabetes care, but more research is needed, especially of electronic feedback. PMID:19419548

Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes.

PubMed

Chamberlain, James J; Kalyani, Rita Rastogi; Leal, Sandra; Rhinehart, Andrew S; Shubrook, Jay H; Skolnik, Neil; Herman, William H

2017-10-03

The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.

Need and disparities in primary care management of patients with diabetes

PubMed Central

2014-01-01

Background An aging population means that chronic illnesses, such as diabetes, are becoming more prevalent and demands for care are rising. Members of primary care teams should organize and coordinate patient care with a view to improving quality of care and impartial adherence to evidence-based practices for all patients. The aims of the present study were: to ascertain the prevalence of diabetes in an Italian population, stratified by age, gender and citizenship; and to identify the rate of compliance with recommended guidelines for monitoring diabetes, to see whether disparities exist in the quality of diabetes patient management. Methods A population-based analysis was performed on a dataset obtained by processing public health administration databases. The presence of diabetes and compliance with standards of care were estimated using appropriate algorithms. A multilevel logistic regression analysis was applied to assess factors affecting compliance with standards of care. Results 1,948,622 Italians aged 16+ were included in the study. In this population, 105,987 subjects were identified as having diabetes on January 1st, 2009. The prevalence of diabetes was 5.43% (95% CI 5.33-5.54) overall, 5.87% (95% CI 5.82-5.92) among males, and 5.05% (95% CI 5.00-5.09) among females. HbA1c levels had been tested in 60.50% of our diabetic subjects, LDL cholesterol levels in 57.50%, and creatinine levels in 63.27%, but only 44.19% of the diabetic individuals had undergone a comprehensive assessment during one year of care. Statistical differences in diabetes care management emerged relating to gender, age, diagnostic latency period, comorbidity and citizenship. Conclusions Process management indicators need to be used not only for the overall assessment of health care processes, but also to monitor disparities in the provision of health care. PMID:25011729

Diabetes Care in Iran: Where We Stand and Where We Are Headed.

PubMed

Noshad, Sina; Afarideh, Mohsen; Heidari, Behnam; Mechanick, Jeffrey I; Esteghamati, Alireza

2015-01-01

The prevalence of diabetes has steadily increased in Iran from the time of the first published nationally representative survey in 1999 and despite efforts and strategies to reduce disease burden. The aim of the present review was to describe the current status of diabetes care in Iran. A selective review of the relevant literature, focusing on properly conducted studies, describing past and present diabetes care strategies, policies, and outcomes in Iran was performed. The quality of diabetes care has gradually improved as suggested by a reduction in the proportion of undiagnosed patients and an increase in affordability of diabetes medications. The National Program for Prevention and Control of Diabetes has proven successful at identifying high-risk individuals, particularly in rural and remote-access areas. Unfortunately, the rising tide of diabetes is outpacing these efforts by a considerable margin. Substantial opportunities and challenges in the areas of prevention, diagnosis, and management of diabetes exist in Iran that need to be addressed to further improve the quality of care and clinical outcomes. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Diabetes-related quality of life and the demands and burdens of diabetes care among emerging adults with type 1 diabetes in the year after high school graduation.

PubMed

Hanna, Kathleen M; Weaver, Michael T; Slaven, James E; Fortenberry, J Dennis; DiMeglio, Linda A

2014-10-01

The roles of glycemic control, diabetes management, diabetes care responsibility, living independently of parents, and time since high school graduation in predicting diabetes-related quality of life (DQOL) were examined in 184 emerging adults with type 1 diabetes. Data were collected at graduation and 1 year later. Analyses controlling for selected covariates were completed using generalized linear mixed models. Better diabetes management was associated with more positive responses on all four dimensions of DQOL. Impact and worry of DQOL were greater in the presence of depressive symptoms, and life satisfaction was lower. DQOL life satisfaction was lower in those living independently of parents. Young women reported poorer diabetes-related health status than did young men. Time since graduation was not linked to DQOL. Further research is needed on ways to improve DQOL in conjunction with diabetes management and on ways that families can support DQOL when youth live independently. © 2014 Wiley Periodicals, Inc.

12. Children and Adolescents: Standards of Medical Care in Diabetes-2018.

PubMed

2018-01-01

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes 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, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC. © 2017 by the American Diabetes Association.

Quality of Diabetes Management in Saudi Arabia: A Review of Existing Barriers.

PubMed

Almutairi, Khalid M

2015-12-01

Diabetes mellitus is a complex disorder that requires continuous management and medical care. The purpose of this review is to identify and summarize the barriers that affect diabetes management in Saudi Arabia. Studies that have examined the quality of diabetes management in Saudi Arabia were identified through online and manual literature searches. Two researchers independently searched and assessed for inclusion/exclusion criteria. All studies were screened by a specialist for the significance of the review. Studies that were included were evaluated for relevance, methodological rigor, and credibility by giving a quality score based on Russell and Gregory's criteria. This review presents an overview of the quality of diabetes management and issues and barriers concerning the improvement of diabetes care in Saudi Arabia. The online literature search yielded 11 studies which met the inclusion criteria. Factors affecting the quality of diabetes care can be categorized into patient factors (such as adherence, compliance, attitudes, beliefs, knowledge, financial resources and co-morbidities) and healthcare providers' factors (including beliefs, attitudes and knowledge, patient - provider interaction and communication). The identified barriers, both from patients and healthcare providers, will help healthcare authorities to improve diabetes management in Saudi Arabia. Improvement of health awareness about disease and disease management should be tailored through continuous patient education. Continuous training and seminars will also expand providers' knowledge that will ensure quality and effective diabetes management.

The Impact of New Payment Models on Quality of Diabetes Care and Outcomes.

PubMed

McGinley, Erin L; Gabbay, Robert A

2016-06-01

Historic changes in healthcare reimbursement and payment models due to the Affordable Care Act in the United States have the potential to transform how providers care for chronic diseases such as diabetes. Payment experimentation has provided insights into how changing incentives for primary care providers can yield improvements in the triple aim: improving patient experience, improving the health of populations, and reducing costs of healthcare. Much of this has involved leveraging widespread adoption of the patient-centered medical home (PCMH) with diabetes often the focus. While evidence is mounting that the PCMH can improve diabetes outcomes, some PCMH demonstrations have displayed mixed results. One of the first large-scale PCMH demonstrations developed around diabetes was conducted by the Commonwealth of Pennsylvania. Different payment models were employed across a series of staggered regional rollouts that provided a case study for the influence of innovative payment models. These learning laboratories provide insights into the role of reimbursement models and changes in how practice transformation is implemented. Ultimately, evolving payment systems focused on the total cost of care, such as Accountable Care Organizations, hold promise to transform diabetes care and produce significant cost savings through the prevention of complications.

Clinical audit of diabetes management can improve the quality of care in a resource-limited primary care setting.

PubMed

Govender, Indira; Ehrlich, Rodney; Van Vuuren, Unita; De Vries, Elma; Namane, Mosedi; De Sa, Angela; Murie, Katy; Schlemmer, Arina; Govender, Strini; Isaacs, Abdul; Martell, Rob

2012-12-01

To determine whether clinical audit improved the performance of diabetic clinical processes in the health district in which it was implemented. Patient folders were systematically sampled annually for review. Primary health-care facilities in the Metro health district of the Western Cape Province in South Africa. Health-care workers involved in diabetes management. Clinical audit and feedback. The Skillings-Mack test was applied to median values of pooled audit results for nine diabetic clinical processes to measure whether there were statistically significant differences between annual audits performed in 2005, 2007, 2008 and 2009. Descriptive statistics were used to illustrate the order of values per process. A total of 40 community health centres participated in the baseline audit of 2005 that decreased to 30 in 2009. Except for two routine processes, baseline medians for six out of nine processes were below 50%. Pooled audit results showed statistically significant improvements in seven out of nine clinical processes. The findings indicate an association between the application of clinical audit and quality improvement in resource-limited settings. Co-interventions introduced after the baseline audit are likely to have contributed to improved outcomes. In addition, support from the relevant government health programmes and commitment of managers and frontline staff contributed to the audit's success.

Delivery of integrated diabetes care using logistics and information technology--the Joint Asia Diabetes Evaluation (JADE) program.

PubMed

Chan, Juliana C N; Ozaki, Risa; Luk, Andrea; Kong, Alice P S; Ma, Ronald C W; Chow, Francis C C; Wong, Patrick; Wong, Rebecca; Chung, Harriet; Chiu, Cherry; Wolthers, Troels; Tong, Peter C Y; Ko, Gary T C; So, Wing-Yee; Lyubomirsky, Greg

2014-12-01

Diabetes is a global epidemic, and many affected individuals are undiagnosed, untreated, or uncontrolled. The silent and multi-system nature of diabetes and its complications, with complex care protocols, are often associated with omission of periodic assessments, clinical inertia, poor treatment compliance, and care fragmentation. These barriers at the system, patient, and care-provider levels have resulted in poor control of risk factors and under-usage of potentially life-saving medications such as statins and renin-angiotensin system inhibitors. However, in the clinical trial setting, use of nurses and protocol with frequent contact and regular monitoring have resulted in marked differences in event rates compared to epidemiological data collected in the real-world setting. The phenotypic heterogeneity and cognitive-psychological-behavioral needs of people with diabetes call for regular risk stratification to personalize care. Quality improvement initiatives targeted at patient education, task delegation, case management, and self-care promotion had the largest effect size in improving cardio-metabolic risk factors. The Joint Asia Diabetes Evaluation (JADE) program is an innovative care prototype that advocates a change in clinic setting and workflow, coordinated by a doctor-nurse team and augmented by a web-based portal, which incorporates care protocols and a validated risk engine to provide decision support and regular feedback. By using logistics and information technology, supported by a network of health-care professionals to provide integrated, holistic, and evidence-based care, the JADE Program aims to establish a high-quality regional diabetes database to reflect the status of diabetes care in real-world practice, confirm efficacy data, and identify unmet needs. Through collaborative efforts, we shall evaluate the feasibility, acceptability, and cost-effectiveness of this "high tech, soft touch" model to make diabetes and chronic disease care more

Process and outcome measures of quality of care at the diabetes outpatient clinic, University College Hospital, Ibadan.

PubMed

Adeleye, J O; Kuti, M A

2017-02-01

The study aims to assess the quality of care provided at a diabetes outpatient clinic of a tertiary hospital in Nigeria using quality indicators approved by the National Diabetes Quality Improvement Alliance (NDQIA). The medical records of patients who had visited the clinic at least two times within a 12 months period preceding the index visit were reviewed during a 5 month period. Process measure indicators, approved by the NDQIA (evaluating the functioning of the clinic) and outcome measures, published by the American Diabetes Association, (evaluating the health status of the attending patients) were retrieved from the medical records. The 332 records reviewed showed that the most consistently performed process measures were blood pressure and weight measurement (>90%). Foot examination was done infrequently (10.5%). Less than 50% had at least an annual low-density lipoprotein cholesterol (LDL-C) and hemoglobin A1c testing done. The mean (standard deviation) HbA1C (%), LDL-C (mg/dL) systolic blood pressure (SBP) (mmHg), and diastolic blood pressure (DBP) (mmHg) were 7.6 (2.0), 107.3 (31.5), 134.3 (20.8), 79.5 (11.0), respectively. HbA1C >8.0%, LDL-C >130 mg/dL, SBP >130 mmHg, and DBP >90 mmHg) were observed in 34.8%, 21.1%, 40.4%, and 23.8%, respectively. Although the organization of the outpatient services allowed for good performance with regards to "free" services such as blood pressure and weight measurement, it performed suboptimally for foot examinations. Performance indicators that required payment were consistently underperformed. Regular assessment of the quality of care may help in the identification of opportunities for improvement in the organization and delivery of care.

Quality of care for patients with type 2 diabetes mellitus in the Netherlands and the United States: a comparison of two quality improvement programs.

PubMed

Valk, Gerlof D; Renders, Carry M; Kriegsman, Didi M W; Newton, Katherine M; Twisk, Jos W R; van Eijk, Jacques Th M; van der Wal, Gerrit; Wagner, Edward H

2004-08-01

To assess differences in diabetes care and patient outcomes by comparing two multifaceted quality improvement programs in two different countries, and to increase knowledge of effective elements of such programs. Primary care in the ExtraMural Clinic (EMC) of the Department of General Practice of the Vrije Universiteit in Amsterdam, the Netherlands, and the Group Health Cooperative (GHC), a group-model health maintenance organization (HMO) in western Washington State in the United States. Data were collected from 1992 to 1997. In this observational study two diabetes cohorts in which a quality improvement program was implemented were compared. Both programs included a medical record system, clinical practice guidelines, physician educational meetings, audit, and feedback. Only the Dutch program (EMC) included guidelines on the structure of diabetes care and a recall system. Only the GHC program included educational outreach visits, formation of multidisciplinary teams, and patient self-management support. Included were 379 EMC patients, and 2,119 GHC patients with type 2 diabetes mellitus. Main process outcomes were: annual number of diabetes visits, and number of HbA1c and blood lipid measurements. Main patient outcomes were HbA1c and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices. In the EMC process outcomes and glycemic control improved more than at GHC, however, GHC had better baseline measures. There were no differences between programs on blood lipid control. During follow-up, intensification of pharmacotherapy was noted at both sites. Differences noted between programs were in line with differences in diabetes guidelines. Following implementation of guidelines and organizational improvement efforts, change occurred primarily in the process outcomes, rather than in the patient outcomes. Although much effort was put into improving

Longitudinal associations between sex, diabetes self-care, and health-related quality of life among youth with type 1 or type 2 diabetes mellitus.

PubMed

Naughton, Michelle J; Yi-Frazier, Joyce P; Morgan, Timothy M; Seid, Michael; Lawrence, Jean M; Klingensmith, Georgeanna J; Waitzfelder, Beth; Standiford, Debra A; Loots, Beth

2014-06-01

To examine the longitudinal associations between sex, diabetes self-care, and the health-related quality of life (HRQL) of children and adolescents with type 1 or type 2 diabetes. The sample included 910 participants with type 1 and 241 participants with type 2, ages 10-22 years at baseline, from the SEARCH for Diabetes in Youth Study, a longitudinal observational study. The primary outcome measure was the Pediatric Quality of Life Inventory. Repeated measures, mixed-model regression analysis was conducted with the use of data from baseline and at least one follow-up assessment, spanning approximately 4 years. HRQL was greater among those with type 1 versus type 2 diabetes. Among participants with type 1, greater (better) Pediatric Quality of Life Inventory total scores over time were related to greater parent education (P = .0007), lower glycated hemoglobin values (P < .0001), and greater physical activity during the past 7 days (P = .0001). There was a significant interaction between sex and age (P < .0001); girls' HRQL remained stable or decreased over time, whereas males' HRQL increased. For participants with type 2 diabetes, there was no significant interaction by age and sex, but lower total HRQL was related to being female (P = .011) and greater body mass index z-scores (P = .014). HRQL in this cohort varied by diabetes type. The interaction between sex and age for type 1 participants, coupled with poorer HRQL among female than male participants with type 2 diabetes, suggests the impacts of diabetes on HRQL differ by sex and should be considered in clinical management. Encouraging physical activity and weight control continue to be important in improving HRQL. Copyright © 2014 Elsevier Inc. All rights reserved.

Quality of care of patients with type 1 diabetes: population-based results in a French region.

PubMed

Penfornis, A; Personeni, E; Tiv, M; Monnier, C; Meillet, L; Combes, J; Mouret, C; Picard, S

2012-11-01

Although the incidence of type 1 diabetes (T1D) has been increasing, little is known of its quality of care. Thus, our survey was designed to retrospectively evaluate this issue in French patients. Patients with T1D living in northeastern France were identified thanks to the healthcare system (CPAM) database, and the resulting list reviewed by local diabetes specialists. All of the listed patients and their primary physicians were asked to fill in a questionnaire including clinical data, laboratory results and follow-up habits. The 'optimized results' included CPAM-based results plus any specialized care provided during hospitalizations in diabetes and non-diabetes units, according to questionnaire data. A total of 227 individuals, for whom CPAM data were available, were identified as having T1D. From these patients, 174 questionnaires were answered, and optimized results (having both CPAM data and a completely filled-in questionnaire) were available for 149 patients. Of the 169 patients who responded, 71.3% reported at least a yearly visit with a diabetologist. This number reached 77.9% when optimized results were considered. Patients who received specialized care were younger, underwent HbA(1c) tests more often and were more frequently on optimal treatment; however, there was no difference in HbA(1c) values or in the prevalence of complications. Eye examinations and kidney tests had been performed at least once over the 2-year period in more than 87% of the patients, whereas around 30%, 21% and 23% had an eye exam, creatinine test and urinary albumin excretion measurement, respectively, only once over the same time period. This is the first large-scale study of the quality of care in patients with T1DM in France, and it could serve as a preliminary survey for a national study. Although the follow-up was better than previously reported, there is still considerable room for improvement. Copyright © 2012. Published by Elsevier Masson SAS.

The interdisciplinary approach to the implementation of a diabetes home care disease management program.

PubMed

Rosa, Mary Ann; Lapides, Shawn; Hayden, Corrine; Santangelo, Roxanne

2014-02-01

Diabetes is a national epidemic and a leading cause of hospitalizations in the United States. Home care agencies need to be able to provide effective Diabetes Disease Management to help prevent avoidable hospitalizations and assist patients to live a good quality of life. This article describes one organization's journey toward providing patients with better diabetes care resulting in an improved quality of life.

Linking quality of healthcare and health-related quality of life of patients with type 2 diabetes: an evaluative study in Mexican family practice.

PubMed

Doubova, Svetlana V; Mino-León, Dolores; Pérez-Cuevas, Ricardo

2013-12-01

To assess the association between quality of care and health-related quality of life among type 2 diabetes patients. A cross-sectional study assessing the association between quality of care and quality of life using multiple linear regression analysis. Family medicine clinics (FMC) (n = 39) of the Mexican Institute of Social Security (IMSS) in Mexico City. Type 2 diabetes patients (n = 312), older than 19 years. Health-related quality of life was measured using the MOS Short-Form-12 (SF-12); quality of healthcare was measured as the percentage of recommended care received under each of four domains: early detection of diabetes complications, non-pharmacological treatment, pharmacological treatment and health outcomes. The average quality of life score was 41.4 points on the physical component and 47.9 points on the mental component. Assessment of the quality of care revealed deficiencies. The average percentages of recommended care received were 21.9 for health outcomes and 56.6 for early detection of diabetes complications and pharmacological treatment; for every 10 percent additional points on the pharmacological treatment component, quality of life improved by 0.4 points on the physical component (coefficient 0.04, 95% confidence intervals 0.01-0.07). There was a positive association between the quality of pharmacological care and the physical component of quality of life. The quality of healthcare for type 2 diabetes patients in FMC of the IMSS in Mexico City is not optimal.

A Narrative Review of Diabetes Intervention Studies to Explore Diabetes Care Opportunities for Pharmacists.

PubMed

Ayadurai, Shamala; Hattingh, H Laetitia; Tee, Lisa B G; Md Said, Siti Norlina

2016-01-01

Background. We conducted a review of current diabetes intervention studies in type 2 diabetes and identified opportunities for pharmacists to deliver quality diabetes care. Methods. A search on randomised controlled trials (RCT) on diabetes management by healthcare professionals including pharmacists published between 2010 and 2015 was conducted. Results and Discussion. Diabetes management includes multifactorial intervention which includes seven factors as outlined in diabetes guidelines, namely, glycaemic, cholesterol and blood pressure control, medication, lifestyle, education, and cardiovascular risk factors. Most studies do not provide evidence that the intervention methods used included all seven factors with exception of three RCT which indicated HbA1c (glycated hemoglobin) reduction range of 0.5% to 1.8%. The varied HbA1C reduction suggests a lack of standardised and consistent approach to diabetes care. Furthermore, the duration of most studies was from one month to two years; therefore long term outcomes could not be established. Conclusion. Although pharmacists' contribution towards improving clinical outcomes of diabetes patients was well documented, the methods used to deliver structured, consistent evidence-based care were not clearly stipulated. Therefore, approaches to achieving long term continuity of care are uncertain. An intervention strategy that encompass all seven evidence-based factors will be useful.

Emergency room visit: a red-flag indicator for poor diabetes care.

PubMed

Stern, Z; Calderon-Margalit, R; Mazar, M; Brezis, M; Tirosh, A

2009-11-01

To determine the association between emergency room (ER) admission and quality of diabetes care in the community. In a nested case-control study of patients with Type 2 diabetes mellitus (DM) within a large health maintenance organization (HMO) in Israel, 919 patients who were admitted to one of West Jerusalem's ERs between 1 May and 30 June 2004 were compared with 1952 control subjects not admitted. Data on study covariates were retrieved from the HMO's computerized database and a subset of the study population was interviewed. Logistic regressions were conducted to estimate the odds ratios of being admitted according to different measures of quality of care, controlling for socio-demographic variables, co-morbidities and type of DM treatment. The main indices of quality of primary care that were inversely associated with visiting an ER during the study period included performance of a cholesterol test in the year prior to the index date [adjusted odds ratio (OR) 0.23, 95% confidence interval (CI) 0.19-0.29, P < 0.001], performance of glycated haemoglobin test (OR 0.26, 95% CI 0.24-0.29, P < 0.001), visiting an ophthalmologist (OR 0.47, 95% CI 0.32-0.68, P = 0.001), and recommendations to stop smoking (OR 0.10, 95% CI 0.05-0.21, P < 0.001). Admission to the ER can be used as an indicator for poor quality of diabetes care. There is an association between ER admission and poor quality of diabetes care.

Blood glucose control and quality of health care in non-insulin-treated patients with Type 2 diabetes in Spain: a retrospective and cross-sectional observational study

PubMed Central

Rodríguez, A; Calle, A; Vázquez, L; Chacón, F; Polavieja, P; Reviriego, J

2011-01-01

Aims To assess blood glucose control and quality of health care provided to non-insulin-treated patients with Type 2 diabetes mellitus in routine clinical practice in Spain. Methods In this observational, retrospective, cross-sectional study, patients were grouped as either having good or suboptimal blood glucose control according to International Diabetes Federation or American Diabetes Association HbA1c goals. Clinical and socio-demographic data and compliance with the main standard level of care recommendations of the International Diabetes Federation were recorded during a routine visit. Correlates of glucose control were analysed by logistic regression. Results Many patients were grouped as having suboptimal control under International Diabetes Federation (61.9%) or American Diabetes Association (45.0%) criteria. The mean number of accomplished International Diabetes Federation recommendations (7.3 out of 11) was higher for endocrinologists (than for internists or primary care physicians), and significantly more patients under their care were in the good glucose control group (than with primary care physicians). More recommendations were associated with blood glucose control using International Diabetes Federation than American Diabetes Association criteria, demanding higher quality of health care for achieving stricter goals. Some recommendations were poorly observed, particularly those concerning patients’ education on diabetes, the prompt prescription of effective treatments and monitoring of complications. Diabetes complications were associated with being in the suboptimal control group. Patients’ education on diabetes and HbA1c monitoring were associated with being in the good control group. Conclusions These results demonstrate the need for improvement in the management of patients with non-insulin-treated Type 2 diabetes in actual clinical practice in Spain. Such improvement would entail a stricter adherence to International Diabetes Federation

What part of the total care consumed by type 2 diabetes patients is directly related to diabetes? Implications for disease management programs.

PubMed

van Dijk, Christel E; Verheij, Robert A; Swinkels, Ilse C S; Rijken, Mieke; Schellevis, François G; Groenewegen, Peter P; de Bakker, Dinny H

2011-10-01

Disease management programs (DMP) aim at improving coordination and quality of care and reducing healthcare costs for specific chronic diseases. This paper investigates to what extent total healthcare utilization of type 2 diabetes patients is actually related to diabetes and its implications for diabetes management programs. Healthcare utilization for diabetes patients was analyzed using 2008 self-reported data (n=316) and data from electronic medical records (EMR) (n=9023), and divided whether or not care was described in the Dutch type 2 diabetes multidisciplinary healthcare standard. On average 4.3 different disciplines of healthcare providers were involved in the care for diabetes patients. Ninety-six percent contacted a GP-practice and 63% an ophthalmologist, 24% an internist, 32% a physiotherapist and 23% a dietician. Diabetes patients had on average 9.3 contacts with GP-practice of which 53% were included in the healthcare standard. Only a limited part of total healthcare utilization of diabetes patients was included in the healthcare standard and therefore theoretically included in DMPs. Organizing the care for diabetics in a DMP might harm the coordination and quality of all healthcare for diabetics. DMPs should be integrated in the overall organization of care.

Process of care compliance is associated with fewer diabetes complications

PubMed Central

Bayer, Felicia J.; Galusha, Deron; Slade, Martin; Chu, Isabella M.; Taiwo, Oyebode; Cullen, Mark R.

2014-01-01

Objective To examine the association between processes measures of diabetes care and time to progression for four complications of diabetes - Coronary Artery Disease (CAD), Stroke, Heart Failure (HF), and Renal Disease (RD). Study Design This retrospective study followed outcomes from 2003 through 2009 in a cohort of 1,797 employees with diabetes who worked for a large US manufacturer and were enrolled in the same health insurance plan. Methods Quality of care was measured by consensus standards for testing A1C, lipids and microalbuminuria. Employees with diabetes who received all three measures of care in the baseline year (2003) were compared to those who received less complete testing. Cox proportional hazard regression models were used to assess potential associations between diabetes care and time to complication, controlling for potential confounders. Results Observed differences between the two groups in time-to-event were significant for two of the four complications: HF (HR 0.39, 95% CI [0.19 – 0.81], p = 0.0117), and RD (HR 0.48, 95% CI [0.24 – 0.95], p = 0.0339) and any of the four complications (HR 0.66, 95% CI [0.48 – 0.91], p = 0.0101). Differences in time to complication for CAD (HR 0.70, 95% CI [0.49 – 1.02], p = 0.0635) and Stroke (HR 0.63, 95% CI [0.38 – 1.07], p = 0.0891) showed the same trend but were not significant. Conclusions In this cohort, employees with diabetes who received all three quality measures experienced reduced complication risk - adjusting for other factors. These results provide support for the importance of care quality and its assessment. PMID:24512164

Challenges in Identifying Patients with Type 2 Diabetes for Quality-Improvement Interventions in Primary Care Settings and the Importance of Valid Disease Registries.

PubMed

Wozniak, Lisa; Soprovich, Allison; Rees, Sandra; Johnson, Steven T; Majumdar, Sumit R; Johnson, Jeffrey A

2015-10-01

Patient registries are considered an important foundation of chronic disease management, and diabetes patient registries are associated with better processes and outcomes of care. The purpose of this article is to describe the development and use of registries in the Alberta's Caring for Diabetes (ABCD) project to identify and reach target populations for quality-improvement interventions in the primary care setting. We applied the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework and expanded the definition of reach beyond the individual (i.e. patient) level to include the ability to identify target populations at an organizational level. To characterize reach and the implementation of registries, semistructured interviews were conducted with key informants, and a usual-care checklist was compiled for each participating Primary Care Network (PCN). Content analysis was used to analyze qualitative data. Using registries to identify and recruit participants for the ABCD interventions proved challenging. The quality of the registries depended on whether physicians granted PCN access to patient lists, the strategies used in development, the reliability of diagnostic information and the data elements collected. In addition, once a diabetes registry was developed, there was limited ability to update it. Proactive management of chronic diseases like diabetes requires the ability to reach targeted patients at the population level. We observed several challenges to the development and application of patient registries. Given the importance of valid registries, strong collaborations and novel strategies that involve policy-makers, PCNs and providers are needed to help find solutions to improve registry quality and resolve maintenance issues. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Exploring staff diabetes medication knowledge and practices in regional residential care: triangulation study.

PubMed

Wellard, Sally Jane; Rasmussen, Bodil; Savage, Sally; Dunning, Trisha

2013-07-01

This study is drawn from a larger project that aimed to identify the staffing and organisational factors influencing the quality of diabetes care for older people living in residential care in regional Victoria, Australia. The focus of the current study is on medication management for residents with diabetes. With a continuous rise in diabetes in the population, there is an associated increase in the prevalence of diabetes in aged care residential settings. However, there is little specific guidance on how to manage diabetes in older people living in institutional settings who experience multiple concurrent chronic conditions. A triangulation strategy consisting of three phases. A one-shot cross-sectional survey (n = 68) focus group interviews and a case file audit (n = 20). Data were collected between May 2009-January 2010. Staff knowledge of diabetes and its contemporary medication management was found to be suboptimal. Challenges to managing residents with diabetes included limited time, resident characteristics and communication systems. Additionally, the variability in medical support available to residents and a high level of polypharmacy added to the complexity of medication management of resident. The current study suggests administering medicine to residents in aged care settings is difficult and has potentially serious medical, professional and economic consequences. Limitations to staff knowledge of contemporary diabetes care and medications potentially place residents with diabetes at risk of receiving less than optimal diabetes care. Providing evidence-based guidelines about diabetes care in residential care settings is essential to achieve acceptable outcomes and increase the quality of life for residents in public aged care. Continuing education programs in diabetes care specifically related to medication must be provided to all health professionals and encompass scope of practice. © 2013 John Wiley & Sons Ltd.

Diabetes Care in India.

PubMed

Joshi, Shashank R

2015-01-01

Diabetes has become a major health care problem in India with an estimated 66.8 million people suffering from the condition, representing the largest number of any country in the world. The rising burden of diabetes has greatly affected the health care sector and economy in India. The goal of health care experts in India is to transform India into a diabetes care capital in the world. An expert detailed review of the medical literature with an Asian Indian context was performed. Recent epidemiologic studies from India point to a great burden from diabetes. Diabetes control in India is far from ideal with a mean hemoglobin A1c of 9.0%-at least 2.0% higher than suggested by international bodies. Nearly half of people with diabetes remain undetected, accounting for complications at the time of diagnosis. Screening can differentiate an asymptomatic individual at high risk from one at low risk for diabetes. Despite the large number of people with diabetes in India, awareness is low and needs to be addressed. Other challenges include balancing the need for glycemic control with risk reduction due to overly tight control, especially in high-risk groups and taking into account health care professional expertise, attitudes, and perceptions. Pharmacologic care should be individualized with early consideration of combination therapy. Regular exercise, yoga, mindful eating, and stress management form a cornerstone in the management of diabetes. Considering the high cost incurred at various steps of screening, diagnosis, monitoring, and management, it is important to realize the cost-effective measures of diabetes care that are necessary to implement. Result-oriented organized programs involving patient education, as well as updating the medical fraternity on various developments in the management of diabetes, are required to combat the current diabetes epidemic in India. Copyright © 2015. Published by Elsevier Inc.

Benchmarking is associated with improved quality of care in type 2 diabetes: the OPTIMISE randomized, controlled trial.

PubMed

Hermans, Michel P; Elisaf, Moses; Michel, Georges; Muls, Erik; Nobels, Frank; Vandenberghe, Hans; Brotons, Carlos

2013-11-01

To assess prospectively the effect of benchmarking on quality of primary care for patients with type 2 diabetes by using three major modifiable cardiovascular risk factors as critical quality indicators. Primary care physicians treating patients with type 2 diabetes in six European countries were randomized to give standard care (control group) or standard care with feedback benchmarked against other centers in each country (benchmarking group). In both groups, laboratory tests were performed every 4 months. The primary end point was the percentage of patients achieving preset targets of the critical quality indicators HbA1c, LDL cholesterol, and systolic blood pressure (SBP) after 12 months of follow-up. Of 4,027 patients enrolled, 3,996 patients were evaluable and 3,487 completed 12 months of follow-up. Primary end point of HbA1c target was achieved in the benchmarking group by 58.9 vs. 62.1% in the control group (P = 0.398) after 12 months; 40.0 vs. 30.1% patients met the SBP target (P < 0.001); 54.3 vs. 49.7% met the LDL cholesterol target (P = 0.006). Percentages of patients meeting all three targets increased during the study in both groups, with a statistically significant increase observed in the benchmarking group. The percentage of patients achieving all three targets at month 12 was significantly larger in the benchmarking group than in the control group (12.5 vs. 8.1%; P < 0.001). In this prospective, randomized, controlled study, benchmarking was shown to be an effective tool for increasing achievement of critical quality indicators and potentially reducing patient cardiovascular residual risk profile.

The Ohio Gestational Diabetes Postpartum Care Learning Collaborative: Development of a Quality Improvement Initiative to Improve Systems of Care for Women.

PubMed

Shellhaas, Cynthia; Conrey, Elizabeth; Crane, Dushka; Lorenz, Allison; Wapner, Andrew; Oza-Frank, Reena; Bouchard, Jo

2016-11-01

Objectives To improve clinical practice and increase postpartum visit Type 2 diabetes mellitus (T2DM) screening rates in women with a history of gestational diabetes mellitus (GDM). Methods We recruited clinical sites with at least half of pregnant patients enrolled in Medicaid to participate in an 18-month quality improvement (QI) project. To support clinical practice changes, we developed provider and patient toolkits with educational and clinical practice resources. Clinical subject-matter experts facilitated a learning network to train sites and promote discussion and learning among sites. Sites submitted data from patient chart reviews monthly for key measures that we used to provide rapid-cycle feedback. Providers were surveyed at completion regarding toolkit usefulness and satisfaction. Results Of fifteen practices recruited, twelve remained actively engaged. We disseminated more than 70 provider and 2345 patient toolkits. Documented delivery of patient education improved for timely GDM prenatal screening, reduction of future T2DM risk, smoking cessation, and family planning. Sites reported toolkits were useful and easy to use. Of women for whom postpartum data were available, 67 % had a documented postpartum visit and 33 % had a postpartum T2DM screen. Lack of information sharing between prenatal and postpartum care providers was are barriers to provision and documentation of care. Conclusions for Practice QI and toolkit resources may improve the quality of prenatal education. However, postpartum care did not reach optimal levels. Future work should focus on strategies to support coordination of care between obstetrical and primary care providers.

[Ukrainian experience of health care for patients with diabetes].

PubMed

Матюха, Лариса Ф; Титова, Тетяна А; Бухановська, Тетяна М; Смаль, Богдан О

2016-01-01

diabetes mellitus is among the main challenges in the establishment of an effective health care system. A significant prevalence of disease and, consequently, a large number of complications, caused by it, provokes a constant searching for new measures and means for the struggle. In Ukraine, as in other countries, among methods of such a struggle is to standardize medical care. explore the state of health care for patients with diabetes in Ukraine. to study the frequency of the measurement of certain quality indicators of patients with diabetes it was organized cross-sectional trial by the anonymous survey of 242 patients with a previously verified diagnosis of more than 2 years, at services of primary and secondary health care. obtained results are showed the presence of significant weaknesses in the providing of quality health care for patients with diabetes, in comparison with the requirements of national standards. Considering the features of detected flaws, they should be regarded as a result of an insufficient level of knowledge of their disease among patients and, possibly, the low average level of their income. the level of health care for patients of both types of diabetes does not meet recommended. Recommendations, which does not require personal expenses, are realized more efficiently, but not at the target level. Among the Ukrainian population level of implementation of the recommendations related to personal costs spending is at a critically low level, regardless of the type of disease. Solving of the identified problems could be achieved through the development of the network of primary health care services, closer to the patients, in conjunction with the organization and promotion of self-educational projects for patients and their physicians.

[Ukrainian experience of health care for patients with diabetes].

PubMed

Матюха, Лариса Ф; Титова, Тетяна А; Бухановська, Тетяна М; Смаль, Богдан О

diabetes mellitus is among the main challenges in the establishment of an effective health care system. A significant prevalence of disease and, consequently, a large number of complications, caused by it, provokes a constant searching for new measures and means for the struggle. In Ukraine, as in other countries, among methods of such a struggle is to standardize medical care. explore the state of health care for patients with diabetes in Ukraine. to study the frequency of the measurement of certain quality indicators of patients with diabetes it was organized cross-sectional trial by the anonymous survey of 242 patients with a previously verified diagnosis of more than 2 years, at services of primary and secondary health care. obtained results are showed the presence of significant weaknesses in the providing of quality health care for patients with diabetes, in comparison with the requirements of national standards. Considering the features of detected flaws, they should be regarded as a result of an insufficient level of knowledge of their disease among patients and, possibly, the low average level of their income. the level of health care for patients of both types of diabetes does not meet recommended. Recommendations, which does not require personal expenses, are realized more efficiently, but not at the target level. Among the Ukrainian population level of implementation of the recommendations related to personal costs spending is at a critically low level, regardless of the type of disease. Solving of the identified problems could be achieved through the development of the network of primary health care services, closer to the patients, in conjunction with the organization and promotion of self-educational projects for patients and their physicians.

Clinical Audit of Diabetes Care in the Bahrain Defence Forces Hospital

PubMed Central

Al-Baharna, Marwa M.; Whitford, David L.

2013-01-01

Objectives: Primary care audits in Bahrain have consistently revealed a failure to meet recognised standards of delivery of process and outcome measures to patients with diabetes. This study aimed to establish for the first time the quality of diabetes care in a Bahraini hospital setting. Methods: A retrospective clinical audit was conducted of a random sample of patients attending the Diabetes and Endocrine Center at the Bahrain Defence Forces Hospital over a 15-month period which ended in June 2010. The medical records of 287 patients with diabetes were reviewed electronically and manually for process and outcome measures, and a statistical analysis was performed. Results: Of the patients, 47% were male, with a median age of 54 years, and 5% had type 1 diabetes. Measured processes, including haemoglobin A1c, blood pressure, lipids, creatinine and weight, were recorded in over 90% of the patients. Smoking (8%) and the patient’s body mass index (19%) were less frequently recorded. Screening for complications was low, with retinal screening in 42%, foot inspection in 22% and microalbuminuria in 23% of patients. Conclusion: This study shows that the implementation of recognised evidence-based practice continues to pose challenges in routine clinical care. Screening levels for the complications of diabetes were low in this hospital diabetes clinic. It is important to implement a systematic approach to diabetes care to improve the quality of care of patients with diabetes which could lead to a lowering of cardiovascular risk and a reduction in healthcare costs in the long term. PMID:24273661

Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care.

PubMed

Vamos, Eszter P; Pape, Utz J; Bottle, Alex; Hamilton, Fiona Louise; Curcin, Vasa; Ng, Anthea; Molokhia, Mariam; Car, Josip; Majeed, Azeem; Millett, Christopher

2011-09-06

Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management. We conducted a retrospective open-cohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154,945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA(1c)) levels and total cholesterol. We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA(1c) level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19). We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-for-performance programs appear to benefit both large and small practices to a similar extent.

[Health related quality of life among patients with type 2 diabetes mellitus].

PubMed

Urzúa M, Alfonso; Chirino, Alejandra; Valladares, Geraldine

2011-03-01

Type 2 diabetes mellitus may affect profoundly the quality of life of patients. To assess health related quality of life among patients with Type 2 Diabetes Mellitus. The Diabetes Quality of Life (DQOL) questionnaire was applied to 296 patients with diabetes mellitus aged 63 ± lO years (201 women) seen in primary health care centers. The concern about the future effects of diabetes was the worst evaluated domain. Women perceived a lower health related quality of life than men. There was an inverse correlation between age and satisfaction with treatment, concern about vocational, social and future effects of the disease. Type 2 diabetes affects health related quality of life, especially in some specific domains such as perception of the future.

Quality evaluation of JAMA Patient Pages on diabetes using the Ensuring Quality Information for Patient (EQIP) tool.

PubMed

Vaona, Alberto; Marcon, Alessandro; Rava, Marta; Buzzetti, Roberto; Sartori, Marco; Abbinante, Crescenza; Moser, Andrea; Seddaiu, Antonia; Prontera, Manuela; Quaglio, Alessandro; Pallazzoni, Piera; Sartori, Valentina; Rigon, Giulio

2011-12-01

Many medical journals provide patient information leaflets on the correct use of medicines and/or appropriate lifestyles. Only a few studies have assessed the quality of this patient-specific literature. The purpose of this study was to evaluate the quality of JAMA Patient Pages on diabetes using the Ensuring Quality Information for Patient (EQIP) tool. A multidisciplinary group of 10 medical doctors analyzed all diabetes-related Patient Pages published by JAMA from 1998 to 2010 using the EQIP tool. Inter-rater reliability was assessed using the percentage of observed total agreement (p(o)). A quality score between 0 and 1 (the higher score indicating higher quality) was calculated for each item on every page as a function of raters' answers to the EQIP checklist. A mean score per item and a mean score per page were then calculated. We found 8 Patient Pages on diabetes on the JAMA web site. The overall quality score of the documents ranged between 0.55 (Managing Diabetes and Diabetes) and 0.67 (weight and diabetes). p(o) was at least moderate (>50%) for 15 of the 20 EQIP items. Despite generally favorable quality scores, some items received low scores. The worst scores were for the item assessing provision of an empty space to customize information for individual patients (score=0.01, p(o)=95%) and patients involvement in document drafting (score=0.11, p(o)=79%). The Patient Pages on diabetes published by JAMA were found to present weak points that limit their overall quality and may jeopardize their efficacy. We therefore recommend that authors and publishers of written patient information comply with published quality criteria. Further research is needed to evaluate the quality and efficacy of existing written health care information. Copyright © 2011 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Quality of Diabetes Care in Germany Improved from 2000 to 2007 to 2014, but Improvements Diminished since 2007. Evidence from the Population-Based KORA Studies

PubMed Central

Knoll, Gabriella; Schunk, Michaela; Meisinger, Christa; Huth, Cornelia; Holle, Rolf

2016-01-01

Objective Little is known about the development of the quality of diabetes care in Germany. The aim of this study is to analyze time trends in patient self-management, physician-delivered care, medication, risk factor control, complications and quality of life from 2000 to 2014. Methods Analyses are based on data from individuals with type 2 diabetes of the population-based KORA S4 (1999–2001, n = 150), F4 (2006–2008, n = 203), FF4 (2013/14, n = 212) cohort study. Information on patient self-management, physician-delivered care, medication, risk factor control and quality of life were assessed in standardized questionnaires and examinations. The 10-year coronary heart disease (CHD) risk was calculated using the UKPDS risk engine. Time trends were analyzed using multivariable linear and logistic regression models adjusted for age, sex, education, diabetes duration, and history of cardiovascular disease. Results From 2000 to 2014 the proportion of participants with type 2 diabetes receiving oral antidiabetic/cardio-protective medication and of those reaching treatment goals for glycemic control (HbA1c<7%, 60% to 71%, p = 0.09), blood pressure (<140/80 mmHg, 25% to 69%, p<0.001) and LDL cholesterol (<2.6 mmol/l, 13% to 27%, p<0.001) increased significantly. However, improvements were generally smaller from 2007 to 2014 than from 2000 to 2007. Modeled 10-year CHD risk decreased from 30% in 2000 to 24% in 2007 to 19% in 2014 (p<0.01). From 2007 to 2014, the prevalence of microvascular complications decreased and quality of life increased, but no improvements were observed for the majority of indicators of self-management. Conclusion Despite improvements, medication and risk factor control has remained suboptimal. The flattening of improvements and deteriorations in quality of (self-) care since 2007 indicate that more effort is needed to improve quality of care and patient self-management. Due to selection or lead time bias an overestimation of quality of care

Can Secure Patient-Provider Messaging Improve Diabetes Care?

PubMed

Chung, Sukyung; Panattoni, Laura; Chi, Jeffrey; Palaniappan, Latha

2017-10-01

Internet-based secure messaging between patients and providers through a patient portal is now common in the practice of modern medicine. There is limited evidence on how messaging is associated with use and clinical quality measures among patients with type 2 diabetes. We examine whether messaging with physicians for medical advice is associated with fewer face-to-face visits and better diabetes management. Patients with diabetes who were enrolled in an online portal of an outpatient health care organization in 2011-2014 were studied ( N = 37,762 patient-years). Messages from/to primary care physicians or diabetes-related specialists for medical advice were considered. We estimated the association of messaging with diabetes quality measures, adjusting for patient and provider characteristics and patient-level clustering. Most patients (72%) used messaging, and those who made frequent visits were also more likely to message. Given visit frequency, no (vs. any) messaging was negatively associated with the likelihood of meeting an HbA 1c target of <8% (64 mmol/mol) (odds ratio [OR] 0.83 [95% CI 0.77, 0.90]). Among message users, additional messages (vs. 1) were associated with better outcome (two more messages: OR 1.17 [95% CI 1.06, 1.28]; three more messages: 1.38 [1.25, 1.53]; four more messages: 1.55 [1.43, 1.69]). The relationship was stronger for noninsulin users. Message frequency was also positively associated, but to a smaller extent, with process measures (e.g., eye examination). Physician-initiated messages had effects similar to those for patient-initiated messages. Patients with diabetes frequently used secure messaging for medical advice in addition to routine visits to care providers. Messaging was positively associated with better diabetes management in a large community outpatient practice. © 2017 by the American Diabetes Association.

Quality of Care for Patients with Type 2 Diabetes Mellitus in the Netherlands and the United States: A Comparison of Two Quality Improvement Programs

PubMed Central

Valk, Gerlof D; Renders, Carry M; Kriegsman, Didi MW; Newton, Katherine M; Twisk, Jos WR; van Eijk, Jacques ThM; van der Wal, Gerrit; Wagner, Edward H

2004-01-01

Objective To assess differences in diabetes care and patient outcomes by comparing two multifaceted quality improvement programs in two different countries, and to increase knowledge of effective elements of such programs. Study Setting Primary care in the ExtraMural Clinic (EMC) of the Department of General Practice of the Vrije Universiteit in Amsterdam, the Netherlands, and the Group Health Cooperative (GHC), a group-model health maintenance organization (HMO) in western Washington State in the United States. Data were collected from 1992 to 1997. Study Design In this observational study two diabetes cohorts in which a quality improvement program was implemented were compared. Both programs included a medical record system, clinical practice guidelines, physician educational meetings, audit, and feedback. Only the Dutch program (EMC) included guidelines on the structure of diabetes care and a recall system. Only the GHC program included educational outreach visits, formation of multidisciplinary teams, and patient self-management support. Data Collection Included were 379 EMC patients, and 2,119 GHC patients with type 2 diabetes mellitus. Main process outcomes were: annual number of diabetes visits, and number of HbA1c and blood lipid measurements. Main patient outcomes were HbA1c and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices. Principal Findings In the EMC process outcomes and glycemic control improved more than at GHC, however, GHC had better baseline measures. There were no differences between programs on blood lipid control. During follow-up, intensification of pharmacotherapy was noted at both sites. Differences noted between programs were in line with differences in diabetes guidelines. Conclusions Following implementation of guidelines and organizational improvement efforts, change occurred primarily in the process

Improving quality of care using a diabetes registry and disease management services in an integrated delivery network.

PubMed

Campion, Francis X; Tully, George L; Barrett, Jo-Ann; Andre, Paulo; Sweeney, Ann

2005-08-01

Disease management for chronic conditions is a call for collaboration among all parties of the health care system. The Caritas Christi Health Care System established a unified American Diabetes Association (ADA) recognized outpatient diabetes self-management education program (DSME) in each of its six hospital communities and has established an Internet data portal with managed care organizations to improve preventive care for thousands of patients with diabetes. This article describes the stepwise process of building the successful Caritas Diabetes Care Program and the central role of the Caritas Diabetes Registry over a 5-year period.

Quality of Care for Patients with Type 2 Diabetes Mellitus in Dubai: A HEDIS-Like Assessment

PubMed Central

Szabo, Shelagh M.; Osenenko, Katherine M.; Qatami, Lara; Korenblat Donato, Bonnie M.; Korol, Ellen E.; Al Madani, Abdulrazzaq A.; Al Awadi, Fatheya F.; Al-Ansari, Jaber; Maclean, Ross; Levy, Adrian R.

2015-01-01

Objective. As little data are available on the quality of type 2 diabetes mellitus (T2DM) care in the Arabian Gulf States, we estimated the proportion of patients receiving recommended monitoring at the Dubai Hospital for T2DM over one year. Methods. Charts from 150 adults with T2DM were systematically sampled and quality of care was assessed during one calendar year, using a Healthcare Effectiveness Data and Information Set- (HEDIS-) like assessment. Screening for glycosylated haemoglobin (HbA1c), low-density lipoprotein (LDL), blood pressure, retinopathy, and nephropathy was considered. Patients were classified based on their most recent test in the period, and predictors of receiving quality care were examined. Results. Mean age was 58 years (standard deviation (SD): 12.4 years) and 33% were males. Over the year, 98% underwent HbA1c screening (50% had control and 28% displayed poor control); 91% underwent LDL screening (65% had control); 55% had blood pressure control; 30% had retinopathy screening; and 22% received attention for nephropathy. No individual characteristics examined predicted receiving quality care. Conclusion. Some guideline monitoring was conducted for most patients; and rates of monitoring for selected measures were comparable to benchmarks from the United States. Greater understanding of factors leading to high adherence would be useful for other areas of preventive care and other jurisdictions. PMID:26089885

Quality of Care for Patients with Type 2 Diabetes Mellitus in Dubai: A HEDIS-Like Assessment.

PubMed

Szabo, Shelagh M; Osenenko, Katherine M; Qatami, Lara; Korenblat Donato, Bonnie M; Korol, Ellen E; Al Madani, Abdulrazzaq A; Al Awadi, Fatheya F; Al-Ansari, Jaber; Maclean, Ross; Levy, Adrian R

2015-01-01

Objective. As little data are available on the quality of type 2 diabetes mellitus (T2DM) care in the Arabian Gulf States, we estimated the proportion of patients receiving recommended monitoring at the Dubai Hospital for T2DM over one year. Methods. Charts from 150 adults with T2DM were systematically sampled and quality of care was assessed during one calendar year, using a Healthcare Effectiveness Data and Information Set- (HEDIS-) like assessment. Screening for glycosylated haemoglobin (HbA1c), low-density lipoprotein (LDL), blood pressure, retinopathy, and nephropathy was considered. Patients were classified based on their most recent test in the period, and predictors of receiving quality care were examined. Results. Mean age was 58 years (standard deviation (SD): 12.4 years) and 33% were males. Over the year, 98% underwent HbA1c screening (50% had control and 28% displayed poor control); 91% underwent LDL screening (65% had control); 55% had blood pressure control; 30% had retinopathy screening; and 22% received attention for nephropathy. No individual characteristics examined predicted receiving quality care. Conclusion. Some guideline monitoring was conducted for most patients; and rates of monitoring for selected measures were comparable to benchmarks from the United States. Greater understanding of factors leading to high adherence would be useful for other areas of preventive care and other jurisdictions.

Race, socioeconomic status, health-related quality of life, and self-care of type 2 diabetes mellitus among adults in North Carolina.

PubMed

Piper, Crystal N; Chalakalal, Shilpa; Sebastian, Neethu; Warren-Findlow, Jan; Thompson, Michael E

2015-04-01

The objective of this study was to examine the associations among race, education, income, and health-related quality of life (HRQoL) in self-care of type 2 diabetes mellitus among adults in North Carolina. A secondary analysis was conducted using data from the 2009 Behavioral Risk Factor Surveillance Survey (BRFSS), a large population-based survey (N = 432,607) conducted in the United States. The data were analyzed to account for the weighted complex multistage sampling design of the Behavioral Risk Factor Surveillance Survey. Parametric testing using univariate/bivariate/multivariate analysis was performed. The majority of participants reported taking a class/course on diabetes mellitus management and having checked their blood glucose levels at least once per day. The majority (61.26%) of the participants did not have good self-management skills, based on the education and blood glucose-monitoring criteria established for this study. Participants with poor HRQoL had significantly increased odds of good diabetes mellitus self-care practices. Individuals with poor HRQoL had significantly increased odds of good diabetes mellitus self-care practices. Although findings on race, education, and income were not statistically significant, they were consistent with previous research. In the future, individuals who are nonwhite, have less than a high school level of education, and have no health insurance should be targeted to improve diabetes mellitus self-care practices through educational and informational materials. Further investigation using more comprehensive measures of diabetes mellitus self-care is warranted.

The impact of a multidisciplinary self-care management program on quality of life, self-care, adherence to anti-hypertensive therapy, glycemic control, and renal function in diabetic kidney disease: A Cross-over Study Protocol.

PubMed

Helou, Nancy; Talhouedec, Dominique; Shaha, Maya; Zanchi, Anne

2016-07-19

Diabetic kidney disease, a global health issue, remains associated with high morbidity and mortality. Previous research has shown that multidisciplinary management of chronic disease can improve patient outcomes. The effect of multidisciplinary self-care management on quality of life and renal function of patients with diabetic kidney disease has not yet been well established. The aim of this study is to evaluate the impact of a multidisciplinary self-care management program on quality of life, self-care behavior, adherence to anti-hypertensive treatment, glycemic control, and renal function of adults with diabetic kidney disease. A uniform balanced cross-over design is used, with the objective to recruit 40 adult participants with diabetic kidney disease, from public and private out-patient settings in French speaking Switzerland. Participants are randomized in equal number into four study arms. Each participant receives usual care alternating with the multidisciplinary self- care management program. Each treatment period lasts three months and is repeated twice at different time intervals over 12 months depending on the cross-over arm. The multidisciplinary self-care management program is led by an advanced practice nurse and adds nursing and dietary consultations and follow-ups, to the habitual management provided by the general practitioner, the nephrologist and the diabetologist. Data is collected every three months for 12 months. Quality of life is measured using the Audit of Diabetes-Dependent Quality of Life scale, patient self-care behavior is assessed using the Revised Summary of Diabetes Self-Care Activities, and adherence to anti-hypertensive therapy is evaluated using the Medication Events Monitoring System. Blood glucose control is measured by the glycated hemoglobin levels and renal function by serum creatinine, estimated glomerular filtration rate and urinary albumin/creatinine ratio. Data will be analyzed using STATA version 14. The cross

Customer quality and type 2 diabetes from the patients' perspective: a cross-sectional study.

PubMed

Tabrizi, Jafar S; Wilson, Andrew J; O'Rourke, Peter K

2010-12-18

Quality in health care can be seen as having three principal dimensions: service, technical and customer quality. This study aimed to measure Customer Quality in relation to self-management of Type 2 diabetes. A cross-sectional survey of 577 Type 2 diabetes people was carried out in Australia. The 13-item Patient Activation Measure was used to evaluate Customer Quality based on self-reported knowledge, skills and confidence in four stages of self-management. All statistical analyses were conducted using SPSS 13.0. All participants achieved scores at the level of stage 1, but ten percent did not achieve score levels consistent with stage 2 and a further 16% did not reach the actual action stage. Seventy-four percent reported capacity for taking action for self-management and 38% reported the highest Customer Quality score and ability to change the action by changing health and environment. Participants with a higher education attainment, better diabetes control status and those who maintain continuity of care reported a higher Customer Quality score, reflecting higher capacity for self-management. Specific capacity building programs for health care providers and people with Type 2 diabetes are needed to increase their knowledge and skills; and improve their confidence to self-management, to achieve improved quality of delivered care and better health outcomes.

Diabetes - taking care of your feet

MedlinePlus

Diabetes - foot care - self-care; Diabetic foot ulcer - foot care; Diabetic neuropathy - foot care ... else to check your feet. Call your health care provider right way about any foot problems you ...

The Impact of Electronic Health Records and Teamwork on Diabetes Care Quality

PubMed Central

Graetz, Ilana; Huang, Jie; Brand, Richard; Shortell, Stephen M.; Rundall, Thomas G.; Bellows, Jim; Hsu, John; Jaffe, Marc; Reed, Mary E.

2016-01-01

Objective Evidence of the impact Electronic Health Records (EHR) on clinical outcomes remains mixed. The impact EHRs likely depends on the organizational context in which they are used. We focus on one aspect of the organizational context: cohesion of primary care teams. We examined whether team cohesion among primary care team members changed the association of EHR use and changes in clinical outcomes for patients with diabetes. Study Design We combined provider-reported primary care team cohesion with lab values for patients with diabetes collected during the staggered EHR implementation (2005–2009). We used multivariate regression models with patient-level fixed effects to assess whether team cohesion levels changed the association between outpatient EHR use and clinical outcomes for patients with diabetes. Subjects 80,611 patients with diabetes mellitus. Measures Changes in hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) Results For HbA1c, EHR use was associated with an average decrease of 0.11% for patients with higher cohesion primary care teams compared with a decrease of 0.08% for patients with lower cohesion teams (difference 0.02% in HbA1c, 95%CI: 0.01–0.03). For LDL-C, EHR use was associated with a decrease of 2.15 mg/dL for patients with higher cohesion primary teams compared with a decrease of 1.42 mg/dL for patients with lower cohesion teams (difference 0.73 mg/dL, 95%CI: 0.41–1.11 mg/dL). Conclusions Patients cared for by higher cohesion primary care teams experienced modest but statistically significantly greater EHR-related health outcome improvements, compared with patients cared for by providers practicing in lower cohesion teams. PMID:26671699

Diabetes technology: improving care, improving patient-reported outcomes and preventing complications in young people with Type 1 diabetes.

PubMed

Prahalad, P; Tanenbaum, M; Hood, K; Maahs, D M

2018-04-01

With the evolution of diabetes technology, those living with Type 1 diabetes are given a wider arsenal of tools with which to achieve glycaemic control and improve patient-reported outcomes. Furthermore, the use of these technologies may help reduce the risk of acute complications, such as severe hypoglycaemia and diabetic ketoacidosis, as well as long-term macro- and microvascular complications. In addition, diabetes technology can have a beneficial impact on psychosocial health by reducing the burden of diabetes. Unfortunately, diabetes goals are often unmet and people with Type 1 diabetes too frequently experience acute and long-term complications of this condition, in addition to often having less than ideal psychosocial outcomes. Increasing realization of the importance of patient-reported outcomes is leading to diabetes care delivery becoming more patient-centred. Diabetes technology in the form of medical devices, digital health and big data analytics have the potential to improve clinical care and psychosocial support, resulting in lower rates of acute and chronic complications, decreased burden of diabetes care, and improved quality of life. © 2018 Diabetes UK.

The psychometric testing of the diabetes health promotion self-care scale.

PubMed

Wang, Ruey-Hsia; Lin, Li-Ying; Cheng, Chung-Ping; Hsu, Min-Tao; Kao, Chia-Chan

2012-06-01

Health-promoting behavior is an important strategy to maintain and enhance health of patients with Type 2 diabetes. Few instruments have been developed to measure health promotion self-care behavior of patients with Type 2 diabetes. Developing and psychometric testing of the Chinese version of the Diabetes Health Promotion Self-Care Scale (DHPSC) for patients with Type 2 diabetes. Four hundred and eighty-nine patients with Type 2 diabetes were recruited from endocrine clinics in four hospitals in Kaohsiung City in southern Taiwan. Exploratory and confirmatory factor analyses were used to assess the construct validity of the scale. Correlations between the DHPSC and the satisfaction subscale of Diabetes Quality of Life, Diabetes Empowerment Scale, and HbA1c were calculated to evaluate concurrent validity. Internal consistency and test-retest reliability were used to assess the reliability of the scale. The study was conducted in 2007 and 2008. A proposed second-order factor model with seven subscales and 26 items fit the data well. The seven subscales were interpersonal relationships, diet, blood glucose self-monitoring, personal health responsibility, exercise, adherence to the recommended regimens, and foot care. The DHPSC statistically significantly correlated with the satisfaction subscale of Diabetes Quality of Life and the Diabetes Empowerment Scale. HbA1c only statistically significantly correlated with the subscale of health responsibility. Reliability was supported by acceptable Cronbach's alpha (range, .78-.94) and test-retest reliability (range, .76-.95). The DHPSC has satisfactory reliability and validity. Healthcare providers can use the DHPSC to comprehensively assess the health promotion self-care behaviors of patients with Type 2 diabetes.

New Approaches to Providing Individualized Diabetes Care in the 21st Century

PubMed Central

Powell, Priscilla W.; Corathers, Sarah D.; Raymond, Jennifer; Streisand, Randi

2016-01-01

Building from a foundation of rapid innovation, the 21st century is poised to offer considerable new approaches to providing modern diabetes care. The focus of this paper is the evolving role of diabetes care providers collaboratively working with patients and families toward the goals of achieving optimal clinical and psychosocial outcomes for individuals living with diabetes. Advances in monitoring, treatment and technology have been complemented by trends toward patient-centered care with expertise from multiple health care disciplines. The evolving clinical care delivery system extends far beyond adjustment of insulin regimens. Effective integration of patient-centered strategies, such as shared-decision making, motivational interviewing techniques, shared medical appointments, and multidisciplinary team collaboration, into a dynamic model of diabetes care delivery holds promise in reaching glycemic targets and improving patients’ quality of life. PMID:25901504

Fifteen years of continuous improvement of quality care of type 2 diabetes mellitus in primary care in Catalonia, Spain.

PubMed

Mata-Cases, M; Roura-Olmeda, P; Berengué-Iglesias, M; Birulés-Pons, M; Mundet-Tuduri, X; Franch-Nadal, J; Benito-Badorrey, B; Cano-Pérez, J F

2012-03-01

To assess the evolution of type 2 diabetes mellitus (T2DM) quality indicators in primary care centers (PCC) as part of the Group for the Study of Diabetes in Primary Care (GEDAPS) Continuous Quality Improvement (GCQI) programme in Catalonia. Sequential cross-sectional studies were performed during 1993-2007. Process and outcome indicators in random samples of patients from each centre were collected. The results of each evaluation were returned to each centre to encourage the implementation of correcting interventions. Sixty-four different educational activities were performed during the study period with the participation of 2041 professionals. Clinical records of 23,501 patients were evaluated. A significant improvement was observed in the determination of some annual process indicators: HbA(1c) (51.7% vs. 88.9%); total cholesterol (75.9% vs. 90.9%); albuminuria screening (33.9% vs. 59.4%) and foot examination (48.9% vs. 64.2%). The intermediate outcome indicators also showed significant improvements: glycemic control [HbA(1c) ≤ 7% (< 57 mmol/mol); (41.5% vs. 64.2%)]; total cholesterol [≤ 200 mg/dl (5.17 mmol/l); (25.5% vs. 65.6%)]; blood pressure [≤ 140/90 mmHg; (45.4% vs. 66.1%)]. In addition, a significant improvement in some final outcome indicators such as prevalence of foot ulcers (7.6% vs. 2.6%); amputations (1.9% vs. 0.6%) and retinopathy (18.8% vs. 8.6%) was observed. Although those changes should not be strictly attributed to the GCQI programme, significant improvements in some process indicators, parameters of control and complications were observed in a network of primary care centres in Catalonia. © 2012 Blackwell Publishing Ltd.

Fifteen years of continuous improvement of quality care of type 2 diabetes mellitus in primary care in Catalonia, Spain

PubMed Central

Mata-Cases, M; Roura-Olmeda, P; Berengué-Iglesias, M; Birulés-Pons, M; Mundet-Tuduri, X; Franch-Nadal, J; Benito-Badorrey, B; Cano-Pérez, J F

2012-01-01

Aims To assess the evolution of type 2 diabetes mellitus (T2DM) quality indicators in primary care centers (PCC) as part of the Group for the Study of Diabetes in Primary Care (GEDAPS) Continuous Quality Improvement (GCQI) programme in Catalonia. Methods Sequential cross-sectional studies were performed during 1993–2007. Process and outcome indicators in random samples of patients from each centre were collected. The results of each evaluation were returned to each centre to encourage the implementation of correcting interventions. Sixty-four different educational activities were performed during the study period with the participation of 2041 professionals. Results Clinical records of 23,501 patients were evaluated. A significant improvement was observed in the determination of some annual process indicators: HbA1c (51.7% vs. 88.9%); total cholesterol (75.9% vs. 90.9%); albuminuria screening (33.9% vs. 59.4%) and foot examination (48.9% vs. 64.2%). The intermediate outcome indicators also showed significant improvements: glycemic control [HbA1c ≤ 7% (< 57 mmol/mol); (41.5% vs. 64.2%)]; total cholesterol [≤ 200 mg/dl (5.17 mmol/l); (25.5% vs. 65.6%)]; blood pressure [≤ 140/90 mmHg; (45.4% vs. 66.1%)]. In addition, a significant improvement in some final outcome indicators such as prevalence of foot ulcers (7.6% vs. 2.6%); amputations (1.9% vs. 0.6%) and retinopathy (18.8% vs. 8.6%) was observed. Conclusions Although those changes should not be strictly attributed to the GCQI programme, significant improvements in some process indicators, parameters of control and complications were observed in a network of primary care centres in Catalonia. PMID:22340449

Do quality improvement initiatives for diabetes care address social inequities? Secondary analysis of a systematic review.

PubMed

Lu, Jacquie Boyang; Danko, Kristin J; Elfassy, Michael D; Welch, Vivian; Grimshaw, Jeremy M; Ivers, Noah M

2018-02-14

Socially disadvantaged populations carry a disproportionate burden of diabetes-related morbidity and mortality. There is an emerging interest in quality improvement (QI) strategies in the care of patients with diabetes, however, the effect of these interventions on disadvantaged groups remains unclear. This is a secondary analysis of a systematic review that seeks to examine the extent of equity considerations in diabetes QI studies, specifically quantifying the proportion of studies that target interventions toward disadvantaged populations and conduct analyses on the impact of interventions on disadvantaged groups. Studies were identified using Medline, HealthStar and the Cochrane Effective Practice and Organisation of Care database. Randomised controlled trials assessing 12 QI strategies targeting health systems, healthcare professionals and/or patients for the management of adult outpatients with diabetes were eligible. The place of residence, race/ethnicity/culture/language, occupational status, gender/sexual identity, religious affiliations, education level, socioeconomic status, social capital, plus age, disability, sexual preferences and relationships (PROGRESS-Plus) framework was used to identify trials that focused on disadvantaged patient populations, to examine the types of equity-relevant factors that are being considered and to explore temporal trends in equity-relevant diabetes QI trials. Of the 278 trials that met the inclusion criteria, 95 trials had equity-relevant considerations. These include 64 targeted trials that focused on a disadvantaged population with the aim to improve the health status of that population and 31 general trials that undertook subgroup analyses to assess the extent to which their interventions may have had differential impacts on disadvantaged subgroups. Trials predominantly focused on race/ethnicity, socioeconomic status and place of residence as potential factors for disadvantage in patients receiving diabetes care. Less

Diabetes Care in Venezuela.

PubMed

Nieto-Martínez, Ramfis; González-Rivas, Juan P; Lima-Martínez, Marcos; Stepenka, Victoria; Rísquez, Alejandro; Mechanick, Jeffrey I

2015-01-01

The incidence of type 2 diabetes (T2D) and its economic burden have increased in Venezuela, posing difficult challenges in a country already in great turmoil. The aim of this study was to review the prevalence, causes, prevention, management, health policies, and challenges for successful management of diabetes and its complications in Venezuela. A comprehensive literature review spanning 1960 to 2015 was performed. Literature not indexed also was reviewed. The weighted prevalence of diabetes and prediabetes was estimated from published regional and subnational population-based studies. Diabetes care strategies were analyzed. In Venezuela, the weighted prevalence of diabetes was 7.7% and prediabetes was 11.2%. Diabetes was the fifth leading cause of death (7.1%) in 2012 with the mortality rate increasing 7% per year from 1990 to 2012. In 2012, cardiovascular disease and diabetes together were the leading cause of disability-adjusted life years.T2D drivers are genetic, epigenetic, and lifestyle, including unhealthy dietary patterns and physical inactivity. Obesity, insulin resistance, and metabolic syndrome are present at lower cutoffs for body mass index, homeostatic model assessment, and visceral or ectopic fat, respectively. Institutional programs for early detection and/or prevention of T2D have not been established. Most patients with diabetes (∼87%) are cared for in public facilities in a fragmented health system. Local clinical practice guidelines are available, but implementation is suboptimal and supporting information is limited. Strategies to improve diabetes care in Venezuela include enhancing resources, reducing costs, improving education, implementing screening (using Latin America Finnish Diabetes Risk Score), promoting diabetes care units, avoiding insulin levels as diagnostic tool, correct use of oral glucose tolerance testing and metformin as first-line T2D treatment, and reducing health system fragmentation. Use of the Venezuelan adaptation of

Into the abyss: diabetes process of care indicators and outcomes of defaulters from a Canadian tertiary care multidisciplinary diabetes clinic

PubMed Central

2013-01-01

Background Continuity of care is essential for good quality diabetes management. We recently found that 46% of patients defaulted from care (had no contact with the clinic for 18 months after a follow-up appointment was ordered) in a Canadian multidisciplinary tertiary care diabetes clinic. The primary aim was to compare characteristics, diabetes processes of care, and outcomes from referral to within 1 year after leaving clinic or to the end of the follow-up period among those patients who defaulted, were discharged or were retained in the clinic. Methods Retrospective cohort study of 193 patients referred to the Foustanellas Endocrine and Diabetes Center (FEDC) for type 2 diabetes from January 1, 2005 to June 30, 2005. The FEDC is the primary academic referral centre for the Ottawa Region and provides multidisciplinary diabetes management. Defaulters (mean age 58.5 ± 12.5 year, 60% M) were compared to patients who were retained in the clinic (mean age 61.4 ± 10.47 years, 49% M) and those who were formally discharged (mean age 61.5 ± 13.2 years, 53.3% M). The chart audit population was then individually linked on an individual patient basis for laboratory testing, physician visits billed through OHIP, hospitalizations and emergency room visits using Ontario health card numbers to health administrative data from the Ministry of Health and Long-Term Care at the Institute for Clinical and Evaluative Sciences (ICES). Results Retained and defaulted patients had significantly longer duration of diabetes, more microvascular complications, were more likely to be on insulin and less likely to have a HbA1c < 7.0% than patients discharged from clinic. A significantly lower proportion of patients who defaulted from tertiary care received recommended monitoring for their diabetes (HbA1c measurements, lipid measurements, and periodic eye examinations), despite no difference in median number of visits to a primary care provider (PCP). Emergency room

Diabetes and the Affordable Care Act

PubMed Central

Schade, David S.

2014-01-01

Abstract The Affordable Care Act—“Obamacare”—is the most important federal medical legislation to be enacted since Medicare. Although the goal of the Affordable Care Act is to improve healthcare coverage, access, and quality for all Americans, people with diabetes are especially poised to benefit from the comprehensive reforms included in the act. Signed into law in 2010, this massive legislation will slowly be enacted over the next 10 years. In the making for at least a decade, it will affect every person in the United States, either directly or indirectly. In this review, we discuss the major changes in healthcare that will take place in the next several years, including (1) who needs to purchase insurance on the Web-based exchange, (2) the cost to individuals and the rebates that they may expect, (3) the rules and regulations for purchasing insurance, (4) the characteristics of the different “metallic” insurance plans that are available, and (5) the states that have agreed to participate. With both tables and figures, we have tried to make the Affordable Care Act both understandable and appreciated. The goal of this comprehensive review is to highlight aspects of the Affordable Care Act that are of importance to practitioners who care for people with diabetes by discussing both the positive and the potentially negative aspects of the program as they relate to diabetes care. PMID:24927108

Physicians' participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study.

PubMed

Heisler, M; Tierney, E; Ackermann, R T; Tseng, C; Narayan, K M Venkat; Crosson, J; Waitzfelder, B; Safford, M M; Duru, K; Herman, W H; Kim, C

2009-09-01

In participatory decision-making (PDM), physicians actively engage patients in treatment and other care decisions. Patients who report that their physicians engage in PDM have better disease self-management and health outcomes. We examined whether physicians' diabetes-specific treatment PDM preferences as well as their self-reported practices are associated with the quality of diabetes care their patients receive. 2003 cross-sectional survey and medical record review of a random sample of diabetes patients (n=4198) in 10 US health plans across the country and their physicians (n=1217). We characterized physicians' diabetes care PDM preferences and practices as 'no patient involvement,' 'physician-dominant,' 'shared,' or 'patient-dominant' and conducted multivariate analyses examining their effects on the following: (1) three diabetes care processes (annual hemoglobin A1c test; lipid test; and dilated retinal exam); (2) patients'satisfaction with physician communication; and (3) whether patients' A1c, systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL) were in control. Most physicians preferred 'shared' PDM (58%) rather than 'no patient involvement' (9%), 'physician-dominant' (28%) or 'patient dominant' PDM (5%). However, most reported practicing 'physician-dominant' PDM (43%) with most of their patients, rather than 'no patient involvement' (13%), 'shared' (37%) or 'patient-dominant' PDM (7%). After adjusting for patient and physician-level characteristics and clustering by health plan, patients of physicians who preferred 'shared' PDM were more likely to receive A1c tests [90% vs. 82%, AOR: 2.05, 95% CI: 1.03-3.07] and patients of physicians who preferred 'patient-dominant' treatment decision-making were more likely to receive lipid tests [60% vs. 50%, AOR: 1.58, 95% CI: 1.04-2.39] than those of providers who preferred 'no patient involvement' in treatment decision-making. There were no differences in patients' satisfaction with their

Challenges of audit of care on clinical quality indicators for hypertension and type 2 diabetes across four European countries.

PubMed

Suija, Kadri; Kivisto, Katrin; Sarria-Santamera, Antonio; Kokko, Simo; Liseckiene, Ida; Bredehorst, Maren; Jaruseviciene, Lina; Papp, Renata; Oona, Marje; Kalda, Ruth

2015-02-01

The purpose of the study was to measure clinical quality by doing an audit of clinical records and to compare the performance based on clinical quality indicators (CQI) for hypertension and type 2 diabetes across seven European countries: Estonia, Finland, Germany, Hungary, Italy, Lithuania and Spain. Two common chronic conditions in primary care (PC), hypertension and type 2 diabetes, were selected for audit. The assessment of CQI started with a literature review of different databases: Organization for Economic Co-operation and Development, World Health Organization, European Commission European Community Health Indicators, US National Library of Medicine. Data were collected from clinical records. Although it was agreed to obtain the clinical indicators in a similar way from each country, the specific data collection process in every country varied greatly, due to different traditions in collecting and keeping the patients' data, as well as differences in regulation regarding access to clinical information. Also, there was a huge variability across countries in the level of compliance with the indicators. Measurement of clinical performance in PC by audit is methodologically challenging: different databases provide different information, indicators of quality of care have insufficient scientific proof and there are country-specific regulations. There are large differences not only in quality of health care across Europe but also in how it is measured. © The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Diabetes self management: are Cuban Americans receiving quality health care?

PubMed

Huffman, Fatma G; Vaccaro, Joan A; Nath, Subrata; Zarini, Gustavo G

2009-01-01

We investigated the relationship among factors predicting inadequate glucose control among 182 Cuban-American adults (Females = 110, Males = 72) with type 2 diabetes mellitus (CAA). Cross-sectional study of CAA from a randomized mailing list in two counties of South Florida. Fasted blood parameters and anthropometric measures were collected during the study. BMI was calculated (kg/m2). Characteristics and diabetes care of CAA were self-reported Participants were screened by trained interviewers for heritage and diabetes status (inclusion criteria: self-reported having type 2 diabetes; age > or = 35 years, male and female; not pregnant or lactating; no thyroid disorders; no major psychiatric disorders). Participants signed informed consent form. Statistical analyses used SPSS and included descriptive statistic, multiple logistic and ordinal logistic regression models, where all CI 95%. Eighty-eight percent of CAA had BMI of > or = 25 kg/m2. Only 54% reported having a diet prescribed/told to schedule meals. We found CAA told to schedule meals were 3.62 more likely to plan meals (1.81, 7.26), p < 0.001) and given a prescribed diet, controlling for age, corresponded with following a meal plan OR 4.43 (2.52, 7.79, p < 0.001). The overall relationship for HbA1c < 8.5 to following a meal plan was OR 9.34 (2.84, 30.7. p < 0.001). The advantage of having a medical professional prescribe a diet seems to be an important environmental support factor in this sample's diabetes care, since obesity rates are well above the national average. Nearly half CAA are not given dietary guidance, yet our results indicate CAA may improve glycemic control by receiving dietary instructions.

The relationships among fear of hypoglycaemia, diabetes-related quality of life and psychological well-being in Norwegian adults with Type 1 diabetes.

PubMed

Strandberg, Ragnhild B; Graue, Marit; Wentzel-Larsen, Tore; Peyrot, Mark; Wahl, Astrid K; Rokne, Berit

2017-02-01

To examine the associations among fear of hypoglycaemia, diabetes-related quality of life and psychological well-being, and determine whether diabetes-related quality of life is a mediator of the relationship between fear of hypoglycaemia and psychological well-being in adults with Type 1 diabetes. A total of 235 of 319 invited adults (18-69years) with Type 1 diabetes agreed to participate. Hierarchical linear regression was applied to 188 individuals with complete data. Mediation analysis was used to determine whether diabetes-related quality of life mediated the relationship between fear of hypoglycaemia and psychological well-being. Fear of hypoglycaemia was significantly associated with diabetes-related quality of life and psychological well-being. The behaviour and worry components of fear of hypoglycaemia were significantly associated with diabetes-related quality of life (behaviour component: unstandardised coefficient=-0.04, p<0.001, standardised coefficient=-0.40; worry component: unstandardised coefficient=-0.01, p=0.041, standardised coefficient=-0.18). Fear of hypoglycaemia worry had a significant independent association with psychological well-being (unstandardised coefficient=-0.28, p=0.009, standardised coefficient=-0.25), whereas fear of hypoglycaemia behaviour did not. Diabetes-related quality of life mediated approximately half of the association between fear of hypoglycaemia worry and psychological well-being. Hypoglycaemic episodes can have serious consequences, and assessing fear of hypoglycaemia might help health care providers offer suitable care strategies to individuals with Type 1 diabetes. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Network and social support in family care of children with diabetes.

PubMed

Pennafort, Viviane Peixoto Dos Santos; Queiroz, Maria Veraci Oliveira; Nascimento, Lucila Castanheira; Guedes, Maria Vilani Cavalcante

2016-01-01

to understand the influence of network and social support in the care of a child with type 1 diabetes. qualitative study, with assumptions of ethnonursing, conducted in a reference service specialized in the treatment of diabetes, in 2014, in the city of Fortaleza, state of Ceará, Brazil. Twenty-six members of the family and their respective school children participated in the study. The process of collection and analysis followed the observation-participation-reflection model. the analytical categories showed that the social network in the care of children with diabetes helped sharing of information and experiences, moments of relaxation and aid in the acquisition of supplies for treatment, with positive repercussions in the family context, generating well-being and confidence in the care of children with diabetes. the cultural care provided by nurses strengthens the network and social support because it encourages autonomy in the promotion of the quality of life of children with type 1 diabetes and their families.

Improving diabetic foot care in a nurse-managed safety-net clinic.

PubMed

Peterson, Joann M; Virden, Mary D

2013-05-01

This article is a description of the development and implementation of a Comprehensive Diabetic Foot Care Program and assessment tool in an academically affiliated nurse-managed, multidisciplinary, safety-net clinic. The assessment tool parallels parameters identified in the Task Force Foot Care Interest Group of the American Diabetes Association's report published in 2008, "Comprehensive Foot Examination and Risk Assessment." Review of literature, Silver City Health Center's (SCHC) 2009 Annual Report, retrospective chart review. Since the full implementation of SCHC's Comprehensive Diabetic Foot Care Program, there have been no hospitalizations of clinic patients for foot-related complications. The development of the Comprehensive Diabetic Foot Assessment tool and the implementation of the Comprehensive Diabetic Foot Care Program have resulted in positive outcomes for the patients in a nurse-managed safety-net clinic. This article demonstrates that quality healthcare services can successfully be developed and implemented in a safety-net clinic setting. ©2012 The Author(s) Journal compilation ©2012 American Association of Nurse Practitioners.

Pharmacologic Therapy for Type 2 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes.

PubMed

Chamberlain, James J; Herman, William H; Leal, Sandra; Rhinehart, Andrew S; Shubrook, Jay H; Skolnik, Neil; Kalyani, Rita Rastogi

2017-04-18

The American Diabetes Association (ADA) annually updates the Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. For the 2017 Standards, the ADA Professional Practice Committee updated previous MEDLINE searches performed from 1 January 2016 to November 2016 to add, clarify, or revise recommendations based on new evidence. The committee rates the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. This synopsis focuses on recommendations from the 2017 Standards about pharmacologic approaches to glycemic treatment of type 2 diabetes.

Rural Health Clinics and Diabetes-Related Primary Care for Medicaid Beneficiaries in Oregon

ERIC Educational Resources Information Center

Kirkbride, Kelly; Wallace, Neal

2009-01-01

Background: This study assessed whether Rural Health Clinics (RHCs) were associated with higher rates of recommended primary care services for adult beneficiaries diagnosed with diabetes in Oregon's Medicaid program, the Oregon Health Plan (OHP). Methods: OHP claims data from 2002 to 2003 were used to assess quality of diabetic care for…

Adaptation and evaluation of the Family Involvement and Alienation Questionnaire for use in the care of older people, psychiatric care, palliative care and diabetes care.

PubMed

Ewertzon, Mats; Alvariza, Anette; Winnberg, Elisabeth; Leksell, Janeth; Andershed, Birgitta; Goliath, Ida; Momeni, Pardis; Kneck, Åsa; Skott, Maria; Årestedt, Kristofer

2018-03-31

To adapt the Family Involvement and Alienation Questionnaire (FIAQ) for use in the care of older people, psychiatric care, palliative care and diabetes care and to evaluate its validity and reliability. Involvement in the professional care has proven to be important for family members. However, they have described feelings of alienation in relation to how they experienced the professionals' approach. To explore this issue, a broad instrument that can be used in different care contexts is needed. A psychometric evaluation study, with a cross-sectional design. The content validity of the FIAQ was evaluated during 2014 by cognitive interviews with 15 family members to adults in different care contexts. Psychometric evaluation was then conducted (2015-2016). A sample of 325 family members participated, 103 of whom in a test-retest evaluation. Both parametric and non-parametric methods were used. The content validity revealed that the questionnaire was generally understood and considered to be relevant and retrievable by family members in the contexts of the care of older people, psychiatric care, palliative care and diabetes care. Furthermore, the FIAQ (Revised), demonstrated satisfactory psychometric properties in terms of data quality, homogeneity, unidimensionality (factor structure), internal consistency and test-retest reliability. The study provides evidence that the FIAQ (Revised) is reliable and valid for use in further research and in quality assessment in the contexts of the care of older people, psychiatric care, palliative care and diabetes care. © 2018 John Wiley & Sons Ltd.

Challenges in managing elderly people with diabetes in primary care settings in Norway

PubMed Central

2013-01-01

Abstract Objective To explore the experiences and clinical challenges that nurses and nursing assistants face when providing high-quality diabetes-specific management and care for elderly people with diabetes in primary care settings. Design Focus-group interviews. Subjects and setting Sixteen health care professionals: 12 registered nurses and four nursing assistants from nursing homes (10), district nursing service (5), and a service unit (1) were recruited by municipal managers who had local knowledge and knew the workforce. All the participants were women aged 32–59 years with clinical experience ranging from 1.5 to 38 years. Results Content analysis revealed a discrepancy between the level of expertise which the participants described as important to delivering high-quality care and their capacity to deliver such care. The discrepancy was due to lack of availability and access to current information, limited ongoing support, lack of cohesion among health care professionals, and limited confidence and autonomy. Challenges to delivering high-quality care included complex, difficult patient situations and lack of confidence to make decisions founded on evidence-based guidelines. Conclusion Participants lacked confidence and autonomy to manage elderly people with diabetes in municipal care settings. Lack of information, support, and professional cohesion made the role challenging. PMID:24205973

Quality of life in patients with diabetic foot ulcer in Visegrad countries.

PubMed

Nemcová, Jana; Hlinková, Edita; Farský, Ivan; Žiaková, Katarína; Jarošová, Darja; Zeleníková, Renáta; Bužgová, Radka; Janíková, Eva; Zdzieblo, Kazimiera; Wiraszka, Grazyna; Stepien, Renata; Nowak-Starz, Grazyna; Csernus, Mariann; Balogh, Zoltan

2017-05-01

To identify the quality of life of patients with diabetic foot ulcers in the Visegrad countries. The diabetics with foot ulcers are principally evaluated on the basis of physical parameters, but this does not always reveal much about the patient's experience of life with ulceration. The cross-sectional study. The standardised generic questionnaire World Health Organization Quality of Life-BREF was used. The sample was made up of 525 participants and the calculations were performed using the IBM spss statistical program. The significant negative correlations between demographic data such as age, duration of diabetes mellitus, duration of diabetic ulceration treatment and a lower level of quality of life were found across the sample. The statistically significant differences according to clinical characteristics such as Wagner classification, frequency of foot ulcers, present peripheral vascular disease and pain in terms of quality of life were also revealed. Significant differences of quality of life among Visegrad countries were revealed: Hungary's participants had a worse quality of life than others, while Slovak participants expressed lower satisfaction with their health than Czech. Socio-demographic factors and clinical characteristics influence the quality of life of patients with diabetic foot ulcer. Significant differences between patients of Visegrad countries were found in all domains of quality of life: physical, psychological, social and environmental. The quality of life of patients with diabetic foot ulcer reflects the conditions and healthcare system in each of the Visegrad countries. We have to respect socio-demographic factors and clinical characteristics in nursing care. This could have an impact on managing patient care not only with regard to their diabetic foot ulcer but also with regard to the patient as a personality with their own problems in relation to physical, psychosocial and environmental conditions. © 2016 John Wiley & Sons Ltd.

Effectiveness of the Smart Care Service for Diabetes Management

PubMed Central

Chung, Young-Soon; Lee, Chang Hee

2014-01-01

Objectives The aim of this study was to assess the effectiveness of the Smart Care service for the diabetes management. Methods Fifty-six patients with diabetes mellitus were recruited in Daegu, Korea. All participants completed a diabetes management education course (diet, exercise, and complications) for their self-care and received access to a care management website through a netbook and smartphone. The website accepts uploads of glucose level, body weight, HbA1c, low-density lipoprotein cholesterol level, and blood pressure. Participants communicated with the care manager through the internal management system of the website. The intervention was applied for 6 months. Results Participants receiving the Smart Care service had lower blood glucose and HbA1c during 6 months follow-up when 1-month values (p < 0.001) were compared. There was no significant difference in body weight and body mass index between 1 month and 6 months. The average number of remote consultation with the Smart Care service per person was 10.4 by nurses, 3.0 by nutritionists, and 1.6 by sports curers. Regression analysis indicated that the number of times counseling was offered by nurses influences body weight and that the number of minutes of telephone counseling influences both body weight and body mass index. Conclusions We have confirmed that the Smart Care service might be an effective system for reduction in blood glucose and HbA1c. We expect that the Smart Care service will contribute to delaying diabetes complications and improving the quality of life of patients with diabetes. PMID:25405065

Effectiveness of the smart care service for diabetes management.

PubMed

Chung, Young-Soon; Kim, Yongsuk; Lee, Chang Hee

2014-10-01

The aim of this study was to assess the effectiveness of the Smart Care service for the diabetes management. Fifty-six patients with diabetes mellitus were recruited in Daegu, Korea. All participants completed a diabetes management education course (diet, exercise, and complications) for their self-care and received access to a care management website through a netbook and smartphone. The website accepts uploads of glucose level, body weight, HbA1c, low-density lipoprotein cholesterol level, and blood pressure. Participants communicated with the care manager through the internal management system of the website. The intervention was applied for 6 months. Participants receiving the Smart Care service had lower blood glucose and HbA1c during 6 months follow-up when 1-month values (p < 0.001) were compared. There was no significant difference in body weight and body mass index between 1 month and 6 months. The average number of remote consultation with the Smart Care service per person was 10.4 by nurses, 3.0 by nutritionists, and 1.6 by sports curers. Regression analysis indicated that the number of times counseling was offered by nurses influences body weight and that the number of minutes of telephone counseling influences both body weight and body mass index. We have confirmed that the Smart Care service might be an effective system for reduction in blood glucose and HbA1c. We expect that the Smart Care service will contribute to delaying diabetes complications and improving the quality of life of patients with diabetes.

The association between depression, quality of life, and the health care expenditure of patients with diabetes mellitus in Uganda

PubMed Central

Akena, Dickens; Kadama, Philippa; Ashaba, Scholastic; Akello, Carolyne; Kwesiga, Brendan; Rejani, Lalitha; Okello, James; Mwesiga, Emmanuel. K.; Obuku, Ekwaro. A.

2015-01-01

Background Depression is one of the commonest neuropsychiatric disorders in patients with diabetes mellitus (DM) and is associated with poor glycaemic control, vascular complications, a low quality of life and increased health care expenditure. Co-morbid DM and depression remains poorly identified and inadequately treated in sub-Saharan Africa. Methods We conducted a cross-sectional survey of 437 patients with DM at 3 DM clinics in Uganda. Participants were assessed for depression, blood sugar levels, diabetic neuropathy, quality of life, and health care expenditures. Results The prevalence of depression was 34.8%. Depressed participants were more likely to be suicidal [OR=3.81, (CI 2.87–5.04)], younger [OR=3.98 CI (1.20–13.23)], un-employed [OR=1.99(CI 1.04–3.81)], and having lost a spouse [OR=2.36 (CI 1.29–4.31)]. Overall quality of life was poor [OR=0.67 (CI 0.47–0.96)], they scored poorer in the physical [OR=0.97, (CI 0.95–0.99)], psychological [OR=1.05 (CI 1.03–1.07)], and environmental [OR=0.97, (CI 0.95–0.99)] domains. They had an increased likelihood of incurring direct out-of-pocket payments for health care services [OR=1.56 (CI 1.03–2.36)], and were more likely to be impoverished [OR=1.52 (CI 1.01–2.28)]. Limitation The cross sectional nature of this study makes it difficult to examine causation. More studies are required in order to better understand the associations and impact of the factors examined above on patient outcomes. Conclusions Depression is highly prevalent among patients with DM in Uganda, and is associated with a number of adverse outcomes. A holistic approach that focuses on the depression management among patients with diabetes is recommended. PMID:25479048

Telemedicine in diabetes foot care delivery: health care professionals' experience.

PubMed

Kolltveit, Beate-Christin Hope; Gjengedal, Eva; Graue, Marit; Iversen, Marjolein M; Thorne, Sally; Kirkevold, Marit

2016-04-18

Introducing new technology in health care is inevitably a challenge. More knowledge is needed to better plan future telemedicine interventions. Our aim was therefore to explore health care professionals' experience in the initial phase of introducing telemedicine technology in caring for people with diabetic foot ulcers. Our methodological strategy was Interpretive Description. Data were collected between 2014 and 2015 using focus groups (n = 10). Participants from home-based care, primary care and outpatient hospital clinics were recruited from the intervention arm of an ongoing cluster randomized controlled trial (RCT) (Clinicaltrials.gov: NCT01710774). Most were nurses (n = 29), but the sample also included one nurse assistant, podiatrists (n = 2) and physicians (n = 2). The participants reported experiencing meaningful changes to their practice arising from telemedicine, especially associated with increased wound assessment knowledge and skills and improved documentation quality. They also experienced more streamlined communication between primary health care and specialist health care. Despite obstacles associated with finding the documentation process time consuming, the participants' attitudes to telemedicine were overwhelmingly positive and their general enthusiasm for the innovation was high. Our findings indicate that using a telemedicine intervention enabled the participating health care professionals to approach their patients with diabetic foot ulcer with more knowledge, better wound assessment skills and heightened confidence. Furthermore, it streamlined the communication between health care levels and helped seeing the patients in a more holistic way.

Trends in the quality of care for elderly people with type 2 diabetes: the need for improvements in safety and quality (the 2001 and 2007 ENTRED Surveys).

PubMed

Pornet, Carole; Bourdel-Marchasson, Isabelle; Lecomte, Pierre; Eschwège, Eveline; Romon, Isabelle; Fosse, Sandrine; Assogba, Frank; Roudier, Candice; Fagot-Campagna, Anne

2011-04-01

This study aimed to characterize the sociodemographic data, health status, quality of care and 6-year trends in elderly people with type 2 diabetes. This study used two French cross-sectional representative surveys of adults of all ages with all types of diabetes (Entred 2001 and 2007), which combined medical claims, and patient and medical provider questionnaires. The 2007 data in patients with type 2 diabetes aged 65 years or over (n=1766) were described and compared with the 2001 data (n=1801). Since 2001, obesity has increased (35% in 2007; +7 points since 2001) while written nutritional advice was less often provided (59%; -6 points). Mean HbA(1c) (7.1%; -0.2%), blood pressure (135/76 mmHg; -4/-3 mmHg) and LDL cholesterol (1.04 g/L; -0.21 g/L) declined, while the use of medication increased: at least two OHAs, 34% (+4 points); OHA(s) and insulin combined, 10% (+4 points); antihypertensive treatment, 83% (+4 points); and statins 48% (+26 points). Severe hypoglycaemia remained frequent (10% had an event at least once a year). The overall prevalence of complications increased. Renal complications were not monitored carefully enough (missing value for albuminuria: 42%; -4.5 points), and 46% of those with a glomerular filtration rate less than 60 mL/min/1.73 m² were taking metformin. Elderly people with type 2 diabetes are receiving better quality of care and have better control of cardiovascular risk factors than before. However, improvement is still required, in particular by performing better screening for complications. In this patient population, it is important to carefully monitor the risks for hypoglycaemia, hypotension, malnutrition and contraindications related to renal function. Copyright © 2011 Elsevier Masson SAS. All rights reserved.

The Diabetes Care Project: an Australian multicentre, cluster randomised controlled trial [study protocol].

PubMed

Leach, Matthew J; Segal, Leonie; Esterman, Adrian; Armour, Caroline; McDermott, Robyn; Fountaine, Tim

2013-12-20

Diabetes mellitus is an increasingly prevalent metabolic disorder that is associated with substantial disease burden. Australia has an opportunity to improve ways of caring for the growing number of people with diabetes, but this may require changes to the way care is funded, organised and delivered. To inform how best to care for people with diabetes, and to identify the extent of change that is required to achieve this, the Diabetes Care Project (DCP) will evaluate the impact of two different, evidence-based models of care (compared to usual care) on clinical quality, patient and provider experience, and cost. The DCP uses a pragmatic, cluster randomised controlled trial design. Accredited general practices that are situated within any of the seven Australian Medicare Locals/Divisions of General Practice that have agreed to take part in the study were invited to participate. Consenting practices will be randomly assigned to one of three treatment groups for approximately 18 to 22 months: (a) control group (usual care); (b) Intervention 1 (which tests improvements that could be made within the current funding model, facilitated through the use of an online chronic disease management network); or (c) Intervention 2 (which includes the same components as Intervention 1, as well as altered funding to support voluntary patient registration with their practice, incentive payments and a care facilitator). Adult patients who attend the enrolled practices and have established (≥12 month's duration) type 1 diabetes mellitus or newly diagnosed or established type 2 diabetes mellitus are invited to participate. Multiple outcomes will be studied, including changes in glycosylated haemoglobin (primary outcome), changes in other biochemical and clinical metrics, incidence of diabetes-related complications, quality of life, clinical depression, success of tailored care, patient and practitioner satisfaction, and budget sustainability. This project responds to a need for robust

The Diabetes Care Project: an Australian multicentre, cluster randomised controlled trial [study protocol

PubMed Central

2013-01-01

Background Diabetes mellitus is an increasingly prevalent metabolic disorder that is associated with substantial disease burden. Australia has an opportunity to improve ways of caring for the growing number of people with diabetes, but this may require changes to the way care is funded, organised and delivered. To inform how best to care for people with diabetes, and to identify the extent of change that is required to achieve this, the Diabetes Care Project (DCP) will evaluate the impact of two different, evidence-based models of care (compared to usual care) on clinical quality, patient and provider experience, and cost. Methods/Design The DCP uses a pragmatic, cluster randomised controlled trial design. Accredited general practices that are situated within any of the seven Australian Medicare Locals/Divisions of General Practice that have agreed to take part in the study were invited to participate. Consenting practices will be randomly assigned to one of three treatment groups for approximately 18 to 22 months: (a) control group (usual care); (b) Intervention 1 (which tests improvements that could be made within the current funding model, facilitated through the use of an online chronic disease management network); or (c) Intervention 2 (which includes the same components as Intervention 1, as well as altered funding to support voluntary patient registration with their practice, incentive payments and a care facilitator). Adult patients who attend the enrolled practices and have established (≥12 month’s duration) type 1 diabetes mellitus or newly diagnosed or established type 2 diabetes mellitus are invited to participate. Multiple outcomes will be studied, including changes in glycosylated haemoglobin (primary outcome), changes in other biochemical and clinical metrics, incidence of diabetes-related complications, quality of life, clinical depression, success of tailored care, patient and practitioner satisfaction, and budget sustainability. Discussion

Diabetes Care in the Philippines.

PubMed

Tan, Gerry H

2015-01-01

Diabetes is increasing at an alarming rate in Asian countries including the Philippines. Both the prevalence and incidence of type 2 diabetes (T2D) continue to increase with a commensurate upward trend in the prevalence of prediabetes. The aim of this study was to review the prevalence of diabetes in the Philippines and to describe extensively the characteristics of diabetes care in the Philippines from availability of diagnostics tests to the procurement of medications. A literature search was performed using the search words diabetes care and Philippines. Articles that were retrieved were reviewed for relevance and then synthesized to highlight key features. The prevalence of diabetes in the Philippines is increasing. Rapid urbanization with increasing dependence on electronic gadgets and sedentary lifestyle contribute significantly to this epidemic. Diabetes care in the Philippines is disadvantaged and challenged with respect to resources, government support, and economics. The national insurance system does not cover comprehensive diabetes care in a preventive model and private insurance companies only offer limited diabetes coverage. Thus, most patients rely on "out-of-pocket" expenses, namely, laboratory procedures and daily medications. Consequently, poor pharmacotherapy adherence impairs prevention of complications. Moreover, behavioral modifications are difficult due to cultural preferences for a traditional diet of refined sugar, including white rice and bread. Translating clinical data into practice in the Philippines will require fundamental and transformative changes that increase diabetes awareness, emphasize lifestyle change while respecting cultural preferences, and promote public policy especially regarding the health insurance system to improve overall diabetes care and outcomes. Copyright © 2015 The Author. Published by Elsevier Inc. All rights reserved.

Opportunities for improved diabetes care among patients of safety net practices: a safety net providers' strategic alliance study.

PubMed

Reichsman, Ann; Werner, James; Cella, Peggi; Bobiak, Sarah; Stange, Kurt C

2009-01-01

To identify barriers and opportunities for quality diabetes care in safety net practices. In 3 federally qualified health centers and 1 free clinic, 19 primary care clinicians profiled patient and visit characteristics and quality of care measures for 181 consecutive visits by adult type 2 diabetic patients. Open-ended questions assessed patient and clinician perception of barriers to diabetes care and patient report of enabling factors. A multidisciplinary team identified themes from open-ended responses. Logistic regression analyses assessed the association of the identified barriers/enablers with 2 measures of quality care: glycosylated hemoglobin and prophylactic aspirin use. Ranked barriers noted by patients included adherence (40%), financial/insurance (23%), and psychosocial (13%) factors. Clinicians ranked systemic factors, including financial/ insurance (32%) and cultural/psychosocial (29%) factors, as important to adherence (29%) in determining quality diabetes care. Patients reported dietary and medical adherence (37%) and family/health care worker support (17%) as helpful factors. Among 175 patients with available data, glycosylated hemoglobin levels were associated with patient report of financial/insurance factors both as a barrier when visits and medications were unaffordable and as an opportunity when free or low-cost medications and services were provided. Patients' adherence with aspirin prophylaxis was strongly associated with African American race, prior prescription of aspirin and distribution of aspirin at the practice site (p<.001). Patients were less likely than clinicians to identify systemic and contextual factors contributing to poor diabetes care. From the front line's perspective, enabling patient self-management and systemic support is a target for improving diabetes care in safety net practices.

Factors driving diabetes care improvement in a large medical group: ten years of progress.

PubMed

Sperl-Hillen, JoAnn M; O'Connor, Patrick J

2005-08-01

The purpose of this study was to document trends in diabetes quality of care and coinciding strategies for quality improvement over 10 years in a large medical group. Adults with diagnosed diabetes mellitus were identified each year from 1994 (N = 5610) to 2003 (N = 7650), and internal medical group data quantified improvement trends. Multivariate analysis was used to identify factors that did and did not contribute to improvement trends. Median glycosylated hemoglobin A1C (A1C) levels improved from 8.3% in 1994 to 6.9% in 2003 (P <.001). Mean low-density lipoprotein (LDL) cholesterol measurements improved from 132 mg/dL in 1995 to 97 mg/dL in 2003 (P <.001). Both A1C (P <.01) and LDL improvement (P <.0001) were driven by drug intensification, leadership commitment to diabetes improvement, greater continuity of primary care, participation in local and national diabetes care improvement initiatives, and allocation of multidisciplinary resources at the clinic level to improve diabetes care. Resources were spent on nurse and dietitian educators, active outreach to high-risk patients facilitated by registries, physician opinion leader activities including clinic-based training programs, and financial incentives to primary care clinics. Use of endocrinology referrals was stable throughout the period at about 10% of patients per year, and there were no disease management contracts to outside vendors over the study period. Electronic medical records did not favorably affect glycemic control or lipid control in this setting. This primary care-based system achieved A1C and LDL reductions sufficient to reduce macrovascular and microvascular risk by about 50% according to landmark studies; further risk reduction should be attainable through better blood pressure control. Strategies for diabetes improvement need to be customized to address documented gaps in quality of care, provider prescribing behaviors, and patient characteristics.

The Analytical Quality of Point-of-Care Testing in the ‘QAAMS’ Model for Diabetes Management in Australian Aboriginal Medical Services

PubMed Central

Shephard, Mark DS; Gill, Janice P

2006-01-01

Type 2 diabetes mellitus and its major complication, renal disease, represent one of the most significant contemporary health problems facing Australia’s Indigenous Aboriginal People. The Australian Government-funded Quality Assurance for Aboriginal Medical Services Program (QAAMS) provides a framework by which on-site point-of-care testing (POCT) for haemoglobin A1c (HbA1c) and now urine albumin:creatinine ratio (ACR) can be performed to facilitate better diabetes management in Aboriginal medical services. This paper provides updated evidence for the analytical quality of POCT in the QAAMS Program. The median imprecision for point-of-care (POC) HbA1c and urine ACR quality assurance (QA) testing has continually improved over the past six and half years, stabilising at approximately 3% for both analytes and proving analytically sound in Aboriginal hands. For HbA1c, there was no statistical difference between the imprecision achieved by QAAMS and laboratory users of the Bayer DCA 2000 since the QAAMS program commenced (QAAMS CV 3.6% ± 0.52, laboratory CV 3.4% ± 0.42; p = 0.21, paired t-test). The Western Pacific Island of Tonga recently joined the QAAMS HbA1c Program indicating that the QAAMS model can also be applied internationally in other settings where the prevalence of diabetes is high. PMID:17581642

Patient understanding of diabetes self-management: participatory decision-making in diabetes care.

PubMed

Quinn, Charlene C; Royak-Schaler, Renee; Lender, Dan; Steinle, Nanette; Gadalla, Shahinaz; Zhan, Min

2011-05-01

Our aim was to determine whether patient participation in decision-making about diabetes care is associated with understanding of diabetes self-management and subsequent self-care practices. We also identified issues that would impact messaging for use in mobile diabetes communication. A cross-sectional observational study was conducted with type 2 diabetes patients (n = 81) receiving their care at the University of Maryland Joslin Diabetes Center. A convenience sample of patients were eligible to participate if they were aged 25-85 years, had type 2 diabetes, spoke English, and visited their physician diabetes manager within the past 6 months. In-person patient interviews were conducted at the time of clinic visits to assess patient understanding of diabetes management, self-care practices, and perceptions of participation in decision-making about diabetes care. African Americans reported fewer opportunities to participate in decision-making than Caucasians, after controlling for education [mean difference (MD) = -2.4, p = .02]. This association became insignificant after controlling for patient-physician race concordance (MD = -1.5, p = .21). Patient understanding of self-care was predicted by having greater than high school education (MD = 3.6, p = .001) and having physicians who involved them in decision-making about their care. For each unit increase in understanding of diabetes self-care, the mean patient self-care practice score increased by 0.16 (p = .003), after adjustment for patient race and education. Patient participation in decision-making is associated with better understanding of care. Participation in decision-making plays a key role in patient understanding of diabetes self-management and subsequent self-care practices. Patients with limited education need specific instruction in foot care, food choices, and monitoring hemoglobin A1c. © 2011 Diabetes Technology Society.

Quality of care in patients with diabetic kidney disease in Asia: The Joint Asia Diabetes Evaluation (JADE) Registry.

PubMed

Luk, A O; Li, X; Zhang, Y; Guo, X; Jia, W; Li, W; Weng, J; Yang, W; Chan, W B; Ozaki, R; Tsang, C C; Mukhopadhyay, M; Ojha, A K; Hong, E G; Yoon, K H; Sobrepena, L; Toledo, R M; Duran, M; Sheu, W; Q Do, T; Nguyen, T K; Ma, R C; Kong, A P; Chow, C C; Tong, P C; So, W Y; Chan, J C

2016-09-01

Diabetic kidney disease independently predicts cardiovascular disease and premature death. We examined the burden of chronic kidney disease (CKD, defined as an estimated GFR < 60 ml/min/1.73 m(2) ) and quality of care in a cross-sectional survey of adults (age ≥ 18 years) with Type 2 diabetes across Asia. The Joint Asia Diabetes Evaluation programme is a disease-management programme implemented using an electronic portal that systematically captures clinical characteristics of all patients enrolled. Between July 2007 and December 2012, data on 28 110 consecutively enrolled patients (China: 3415, Hong Kong: 15 196, India: 3714, Korea: 1651, Philippines: 3364, Vietnam: 692, Taiwan: 78) were analysed. In this survey, 15.9% of patients had CKD, 25.0% had microalbuminuria and 12.5% had macroalbuminuria. Patients with CKD were less likely to achieve HbA1c < 53 mmol/mol (7.0%) (36.0% vs. 42.3%) and blood pressure < 130/80 mmHg (20.8% vs. 35.3%), and were more likely to have retinopathy (26.2% vs. 8.7%), sensory neuropathy (29.0% vs. 7.7%), cardiovascular disease (26.6% vs. 8.7%) and self-reported hypoglycaemia (18.9% vs. 8.2%). Despite high frequencies of albuminuria (74.8%) and dyslipidaemia (93.0%) among CKD patients, only 49.0% were using renin-angiotensin system inhibitors and 53.6% were on statins. On logistic regression, old age, male gender, tobacco use, long disease duration, high HbA1c , blood pressure and BMI, and low LDL cholesterol were independently associated with CKD (all P < 0.05). The poor control of risk factors, suboptimal use of organ-protective drugs and high frequencies of hypoglycaemia highlight major treatment gaps in patients with diabetic kidney disease in Asia. © 2015 Diabetes UK.

Assessment of the quality of primary care for the elderly according to the Chronic Care Model.

PubMed

Silva, Líliam Barbosa; Soares, Sônia Maria; Silva, Patrícia Aparecida Barbosa; Santos, Joseph Fabiano Guimarães; Miranda, Lívia Carvalho Viana; Santos, Raquel Melgaço

2018-03-08

to evaluate the quality of care provided to older people with diabetes mellitus and/or hypertension in the Primary Health Care (PHC) according to the Chronic Care Model (CCM) and identify associations with care outcomes. cross-sectional study involving 105 older people with diabetes mellitus and/or hypertension. The Patient Assessment of Chronic Illness Care (PACIC) questionnaire was used to evaluate the quality of care. The total score was compared with care outcomes that included biochemical parameters, body mass index, pressure levels and quality of life. Data analysis was based on descriptive statistics and multiple logistic regression. there was a predominance of females and a median age of 72 years. The median PACIC score was 1.55 (IQ 1.30-2.20). Among the PACIC dimensions, the "delivery system design/decision support" was the one that presented the best result. There was no statistical difference between the medians of the overall PACIC score and individual care outcomes. However, when the quality of life and health satisfaction were simultaneously evaluated, a statistical difference between the medians was observed. the low PACIC scores found indicate that chronic care according to the CCM in the PHC seems still to fall short of its assumptions.

Diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life over time in Chinese youth with type 1 diabetes.

PubMed

Guo, Jia; Whittemore, Robin; Jeon, Sangchoon; Grey, Margaret; Zhou, Zhi-Guang; He, Guo-Ping; Luo, Zi-Qiang

2015-05-01

To describe the patterns of diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life over time in a cohort of Chinese youth with type 1 diabetes and to determine the relationships between these variables over time. Nurses have an important role in facilitating optimal self-management and health outcomes in youth with type 1 diabetes. Only a few studies have focused on patterns of diabetes adaptation over time in youth with type 1 diabetes, especially in China. Understanding changes in diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life can facilitate assessment and intervention. This is a multi-site longitudinal descriptive study. Data for this report were collected at baseline with 136 eligible Chinese youth and 86 of them were followed up for the second time, 6-12 months after baseline data collection. Instruments to measure diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life were collected at two time points. The data were collected from July 2009-October 2010. Linear mixed model analysis was used to analyse the longitudinal data. Self-management decreased over time; however, depressive symptoms, metabolic control and satisfaction with quality of life did not change from baseline to 6-12 months in this sample of Chinese youth with type 1 diabetes. A decrease in diabetes self-management over time was associated with worse metabolic control, while an increase in depressive symptoms over time was associated with poorer quality of life satisfaction in this sample. Chinese youth faced difficulties with diabetes adaptation, especially with the deterioration of diabetes self-management. Improving self-management and decreasing depressive symptoms may enhance diabetes adaptation with respect to metabolic control and quality of life. The deterioration of diabetes self-management over time in youth with type 1 diabetes in

The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation Among Five Clinics.

PubMed

Sathe, Neha A; Nocon, Robert S; Hughes, Brenna; Peek, Monica E; Chin, Marshall H; Huang, Elbert S

2016-01-01

Quality improvement collaboratives (QICs) support rapid testing and implementation of interventions through the collective experience of participating organizations to improve care quality and reduce costs. Although QICs have been societally cost-effective in improving the care of chronic diseases, they may not be adopted by outpatient clinics if their costs are high. Diabetes QICs warrant reexamination as secular trends in the quality of diabetes care, new care guidelines for diabetes, and evolving strategies for quality improvement may have altered implementation costs. The costs over the first four years-from June 2009 through May 2013-of an ongoing diabetes QIC were characterized by activities and over time. The QIC, linking six clinics on Chicago's South Side, tailored interventions to minority populations and built community partnerships. Costs were calculated from clinic surveys regarding activities, labor, and purchases. Data were obtained from five of the six participating clinics. Cost/diabetic patient/year ranged across clinic sites from $6 (largest clinic) to $68 (smallest clinic). Clinics spent 62%-88% of their total QIC costs on labor. The cost/diabetic patient/year changed over time from Year 1 (range across clinics, $5-$51), Year 2 ($11-$84), Year 3 ($4-$57), to Year 4 ($4-$80), with costs peaking at Year 2 for all clinics except Clinic 4, where costs peaked at Year 4. Cost experiences of QICs in clinics were di- verse over time and setting. High per-patient costs may stem from small clinic size, a sicker patient population, and variation in personnel type used. Cost decreases over time may represent increasing organizational learning and efficiency. Sharing resources may have achieved additional cost savings. This practical information can help administrators and policy makers predict, manage, and support costs of QICs as payers increasingly seek high-value health care.

The Costs of Participating in a Diabetes Quality Improvement Collaborative: Variation Among Five Clinics

PubMed Central

Sathe, Neha A.; Nocon, Robert S.; Hughes, Brenna; Peek, Monica E.; Chin, Marshall H.; Huang, Elbert S.

2016-01-01

Article-at-a-Glance Background Quality improvement collaboratives (QICs) support rapid testing and implementation of interventions through the collective experience of participating organizations to improve care quality and reduce costs. Although QICs have been societally cost-effective in improving the care of chronic diseases, they may not be adopted by outpatient clinics if their costs are high. Diabetes QICs warrant reexamination as secular trends in the quality of diabetes care, new care guidelines for diabetes, and evolving strategies for quality improvement may have altered implementation costs. Methods The costs over the first four years—from June 2009 through May 2013—of an ongoing diabetes QIC were characterized by activities and over time. The QIC, linking six clinics on Chicago’s South Side, tailored interventions to minority populations and built community partnerships. Costs were calculated from clinic surveys regarding activities, labor, and purchases. Results Data were obtained from five of the six participating clinics. Cost/diabetic patient/year ranged across clinic sites from $6 (largest clinic) to $68 (smallest clinic). Clinics spent 62%–88% of their total QIC costs on labor. The cost/diabetic patient/year changed over time from Year 1 (range across clinics, $5–$51), Year 2 ($11–$84), Year 3 ($4–$57), to Year 4 ($4–$80), with costs peaking at Year 2 for all clinics except Clinic 4, where costs peaked at Year 4. Discussion Cost experiences of QICs in clinics were diverse over time and setting. High per-patient costs may stem from small clinic size, a sicker patient population, and variation in personnel type used. Cost decreases over time may represent increasing organizational learning and efficiency. Sharing resources may have achieved additional cost savings. This practical information can help administrators and policy makers predict, manage, and support costs of QICs as payers increasingly seek high-value health care. PMID

Practice context affects efforts to improve diabetes care for primary care patients: a pragmatic cluster randomized trial.

PubMed

Dickinson, L Miriam; Dickinson, W Perry; Nutting, Paul A; Fisher, Lawrence; Harbrecht, Marjie; Crabtree, Benjamin F; Glasgow, Russell E; West, David R

2015-04-01

Efforts to improve primary care diabetes management have assessed strategies across heterogeneous groups of patients and practices. However, there is substantial variability in how well practices implement interventions and achieve desired outcomes. To examine practice contextual features that moderate intervention effectiveness. Secondary analysis of data from a cluster randomized trial of three approaches for implementing the Chronic Care Model to improve diabetes care. Forty small to mid-sized primary care practices participated, with 522 clinician and staff member surveys. Outcomes were assessed for 822 established patients with a diagnosis of type 2 diabetes who had at least one visit to the practice in the 18 months following enrollment. The primary outcome was a composite measure of diabetes process of care, ascertained by chart audit, regarding nine quality measures from the American Diabetes Association Physician Recognition Program: HgA1c, foot exam, blood pressure, dilated eye exam, cholesterol, nephropathy screen, flu shot, nutrition counseling, and self-management support. Data from practices included structural and demographic characteristics and Practice Culture Assessment survey subscales (Change Culture, Work Culture, Chaos). Across the three implementation approaches, demographic/structural characteristics (rural vs. urban + .70(p = .006), +2.44(p < .001), -.75(p = .004)); Medicaid: < 20 % vs. ≥ 20 % (-.20(p = .48), +.75 (p = .08), +.60(p = .02)); practice size: < 4 clinicians vs. ≥ 4 clinicians (+.56(p = .02), +1.96(p < .001), +.02(p = .91)); practice Change Culture (high vs. low: -.86(p = .048), +1.71(p = .005), +.34(p = .22)), Work Culture (high vs. low: -.67(p = .18), +2.41(p < .001), +.67(p = .005)) and variability in practice Change Culture (high vs. low: -.24(p = .006), -.20(p = .0771), -.44(p = .0019) and Work Culture (high vs. low: +.56(p = .3160), -1.0(p = .008), -.25 (p = .0216) were associated with trajectories of change in

Diabetes care: model for the future of primary care.

PubMed

Posey, L Michael; Tanzi, Maria G

2010-01-01

To review relevant trends threatening primary care and the evidence supporting use of nonphysicians in primary and chronic care of patients with diabetes. Current medical and pharmacy literature as selected by authors. The care needed by patients with diabetes does not fit well into our current medical model for primary care, and an adequate supply of physicians is not likely to be available for primary care roles in coming years. Patients with diabetes who are placed on evidence-based regimens, are educated about their disease, are coached in ways that motivate them to lose weight and adopt other therapeutic lifestyle changes, and are adhering to and persisting with therapy will soon have improved clinical parameters. These quickly translate into fewer hospitalizations and emergency department visits. A growing body of literature supports the use of pharmacists and other nonphysicians in meeting the needs of patients with diabetes. Pharmacists should join nurse practitioners, specially trained nurses, and physician assistants as integral members of the health care team in providing care to patients with diabetes and, by logical extension, other chronic conditions. Demand for primary care is likely to outstrip the available supply of generalist physicians in the coming years. In addition to nurse practitioners and physician assistants, pharmacists should be considered for key roles in future interdisciplinary teams that triage and provide direct care to patients, including those with diabetes and other chronic conditions.

Status Update on Translation of Integrated Primary Dental-Medical Care Delivery for Management of Diabetic Patients.

PubMed

Glurich, Ingrid; Nycz, Gregory; Acharya, Amit

2017-06-01

Escalating prevalence of both diabetes and periodontal disease, two diseases associated with bi-directional exacerbation, has been reported. Periodontal disease represents a modifiable risk factor that may reduce diabetes onset or progression, and integrated models of cross-disciplinary care are needed to establish and manage glycemic control in affected patients. An ad-hoc environmental scan of current literature and media sought to characterize factors impacting status of integrated care models based on review of the existing evidence base in literature and media surrounding: (1) current cross-disciplinary practice patterns, (2) epidemiological updates, (3) status on risk assessment and screening for dysglycemia in the dental setting, (4) status on implementation of quality metrics for oral health, (5) care model pilots, and (6) public health perspectives. The survey revealed: escalating prevalence of diabetes and periodontitis globally; greater emphasis on oral health assessment for diabetic patients in recent medical clinical practice guidelines; high knowledgeability surrounding oral-systemic impacts on diabetes and growing receptivity to medical-dental integration among medical and dental providers; increasing numbers of programs/studies reporting on positive impact of emerging integrated dental-medical care models on diabetic patient healthcare access and health outcomes; a growing evidence base for clinically significant rates of undiagnosed dysglycemia among dental patients reported by point-of-care pilot studies; no current recommendation for population-based screening for dysglycemia in dental settings pending a stronger evidence base; improved definition of true periodontitis prevalence in (pre)/diabetics; emerging recognition of the need for oral health quality indicators and tracking; evidence of persistence in dental access disparity; updated status on barriers to integration. The potential benefit of creating clinically-applicable integrated care

The development of integrated diabetes care in the Netherlands: a multiplayer self-assessment analysis.

PubMed

Zonneveld, Nick; Vat, Lidewij E; Vlek, Hans; Minkman, Mirella M N

2017-03-21

Since recent years Dutch diabetes care has increasingly focused on improving the quality of care by introducing the concept of care groups (in Dutch: 'zorggroepen'), care pathways and improving cooperation with involved care professionals and patients. This study examined how participating actors in care groups assess the development of their diabetes services and the differences and similarities between different stakeholder groups. A self-evaluation study was performed within 36 diabetes care groups in the Netherlands. A web-based self-assessment instrument, based on the Development Model for Integrated Care (DMIC), was used to collect data among stakeholders of each care group. The DMIC defines nine clusters of integrated care and four phases of development. Statistical analysis was used to analyze the data. Respondents indicated that the diabetes care groups work together in well-organized multidisciplinary teams and there is clarity about one another's expertise, roles and tasks. The care groups can still develop on elements related to the management and monitoring of performance, quality of care and patient-centeredness. The results show differences (p < 0.01) between three stakeholders groups in how they assess their integrated care services; (1) core players, (2) managers/directors/coordinators and (3) players at a distance. Managers, directors and coordinators assessed more implemented integrated care activities than the other two stakeholder groups. This stakeholder group also placed their care groups in a further phase of development. Players at a distance assessed significantly less present elements and assessed their care group as less developed. The results show a significant difference between stakeholder groups in the assessment of diabetes care practices. This reflects that the professional disciplines and the roles of stakeholders influence the way they asses the development of their integrated care setting, or that certain stakeholder groups

The role of peer support in diabetes care and self-management.

PubMed

Brownson, Carol A; Heisler, Michele

2009-03-01

In light of the growing prevalence and healthcare costs of diabetes mellitus, it is critically important for healthcare providers to improve the efficiency and effectiveness of their diabetes care. A key element of effective disease management for diabetes is support for patient self-management. Barriers to care exist for both patients and healthcare systems. As a result, many people with diabetes do not get the care and support needed to successfully manage their diabetes.Disease management approaches that incorporate peer support may be a promising way to help provide self-management support to patients with diabetes. Trained peers provide emotional support, instrumental (tangible or material) support, education, and skills training to those they serve, and outreach and care coordination for provider systems. They play a unique role that complements and supports clinical care.To describe how peers are currently supporting diabetes care, a number of databases were searched for studies describing the roles of peers using relevant key words. This paper reviews current literature that describes the roles and duties of peers in interventions to improve diabetes care, with a focus on their contributions to six essential elements of self-management support: (i) access to regular, high-quality clinical care; (ii) an individualized approach to assessment and treatment; (iii) patient-centered collaborative goal setting; (iv) education and skills training; (v) ongoing follow-up and support; and (vi) linkages to community resources.Peers worked under a variety of titles, which did not define their duties. The scope of their work ranged from assisting health professionals to playing a central role in care. Providing education and follow-up support were the two most common roles. In all but one study, these roles were carried out during face-to-face contact, most frequently in community sites.A growing body of literature supports the value of peer models for diabetes

Shared Medical Appointments: Impact on Clinical and Quality Outcomes in Veterans With Diabetes.

PubMed

Harris, Marianne D; Kirsh, Susan; Higgins, Patricia A

2016-01-01

Managing diabetes poses substantial challenges to the over 29.1 million Americans afflicted, and is financially overwhelming to the US health care system. One potential strategy is utilizing a group approach to care delivery or shared medical appointment (SMA). The purpose of this 3-year retrospective VA study was to investigate differences in clinical and quality outcome measures in veterans with type 2 diabetes who used SMAs and those who received only usual care (UC) one-on-one with their doctor. This observational, 2-group cohort study used abstracted medical records from a large Midwestern Veterans Administration hospital. Clinical outcome metrics included hemoglobin A1c (hbA1c), systolic blood pressure, low-density lipoprotein cholesterol, and emergency department (ED) visits. Quality outcomes included Veterans' Administration (VA) Department of Defense clinical practice guidelines for the management of diabetes. A total of 988 total VA cases were examined retrospectively over 3 years: 371 cases had used SMAs and 617 were in the UC cohort, and had never attended a diabetes SMA. The study period used abstracted VA medical records from 2008 to 2010. There were no statistically significant differences in HbA1c, systolic blood pressure, and ED visits between groups; however, hbA1c for individuals who attended SMAs was 8.55 (standard deviation [SD] = 1.72) and UC was 7.49 (SD = 1.28) (P < .001). All clinical outcomes were worse at baseline for the SMA cohort. UC had mean ED visits/3 years (mean = 18.62, SD = 13.53, P < .001) versus SMA participants (mean = 27.97, SD = 14.00, P <. 001), revealing a propensity for high health care utilization. SMA providers had statistically significant differences over UC cases on quality measures, including ordering annual ophthalmology and podiatry examinations (P < .001) and prescribing aspirin and angiotension-converting enzyme inhibitors (ACE-I). SMAs may provide a venue for assessing and delivering quality care for patients

Traditional or centralized models of diabetes care: the multidisciplinary diabetes team approach.

PubMed

Bratcher, Christina R; Bello, Elizabeth

2011-11-01

Specialized diabetes care (SDC) centers utilize a multidisciplinary diabetes team to provide patients with highly individualized care. Patients at SDC centers receive their integrated diabetes care in one place--the "one-stop" approach. The components of the SDC center model are: medical care; individualized diabetes education; nutrition; exercise and lifestyle coaching; counseling; monitoring of drug effects. This model results in improved patient outcomes and reduced overall costs.

Patient assessment of diabetes care in a pay-for-performance program.

PubMed

Chiu, Herng-Chia; Hsieh, Hui-Min; Lin, Yi-Chieh; Kuo, Shou-Jen; Kao, Hao-Yun; Yeh, Shu-Chuan Jennifer; Chang, Wen-Hsin; Hsiao, Pi-Jung; Chen, Yao-Shen; Lin, Shoei-Loong; Lo, Gin-Ho; Ker, Chen-Guo; Hung, Yu-Han; Cheng, Hsien-An; Chou, Tiang-Hong; Chou, Sze-Yuan; Wang, Jao-Hsien; Wang, Chien-Fu

2016-04-01

Few studies address quality of care in pay-for-performance (P4P) programs from the perspective of patients' perceptions. This study aimed to examine and compare the patient assessment of diabetes chronic care as perceived by diabetic patients enrolled and not enrolled in a P4P program from the patients' self-reported perspectives. A cross-sectional study with case and comparison group design. A large-scale survey was conducted from February to November 2013 in 18 healthcare institutions in Taiwan. A total of 1458 P4P (n = 1037) and non-P4P (n = 421) diabetic patients participated in this large survey. The Chinese version of the Patient Assessment of Chronic Illness Care (PACIC) instrument was used and patients' clinical outcome data (e.g. HbA1c, LDL) were collected. None. Five subscales from the PACIC were measured, including patient activation, delivery system design/system support, goal setting/tailoring, problem solving/contextual and follow-up/coordination. Patient clinical outcomes were also measured. Multiple linear regression and logistic regression models were used and controlled for patient demographic and health institution characteristics statistically. After adjusting for covariates, P4P patients had higher overall scores on the PACIC and five subscales than non-P4P patients. P4P patients also had better clinical processes of care (e.g. HbA1c test) and intermediate outcomes. Patients who participated in the program likely received better patient-centered care given the original Chronic Care Model. Better perceptions of diabetic care assessment also better clinical outcomes. The PACIC instrument can be used for the patient assessment of chronic care in a P4P program. © The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.

[AMD Annals: a model of continuous monitoring and improvement of the quality of diabetes care].

PubMed

2011-01-01

in recent years, several initiatives have been launched by the Associazione medici diabetologi (AMD) in the context of a national quality improvement program.These activities include: identification of specific indicators of quality of diabetes care, development of a software to calculate such indicators by using routine clinical data, creation of a network of diabetes clinics and analysis and publication of the results in ad hoc reports (AMD Annals). Through the best performer approach, each centre could compare its own performance not only with the theoretical targets suggested by existing guidelines, but also with the results achieved by the best centres operating within the same healthcare system.We evaluated whether the involvement of diabetes clinics into the AMD Annals initiative improved the quality of care over 4 years. a controlled before and after study was performed to compare data collected from 2004 to 2007 by two groups of centres: group A included centres that had been involved in the project since the first edition of AMD Annals; group B included centres only involved in the last edition. overall, 124 diabetes clinics provided data on over 100,000 type 2 diabetes patients/year seen from 2004 to 2007. process indicators included the proportion of patients with at least one measurement of HbA1c, blood pressure and lipid profile during the previous 12 months. Intermediate outcomes included percentages of patients with levels of HbA1c ≤ 7%, blood pressure ≤ 130/85 mmHg and LDL-cholesterol <100 mg/dl (favourable indicators), and the percentages of patients with levels of HbA1c ≥ 9%, blood pressure ≥ 140/90 mmHg and LDL-cholesterol ≥ 130 mg/dl (unfavourable indicators). Percentages of patients treated with insulin, two or more antihypertensive agents, and statins were also evaluated. A multilevel analysis adjusted for age, gender, diabetes duration, and clustering effect was applied to investigate the changes in the indicators between the two

Use of social adaptability index to explain self-care and diabetes outcomes.

PubMed

Campbell, Jennifer A; Walker, Rebekah J; Smalls, Brittany L; Egede, Leonard E

2017-06-20

To examine whether the social adaptability index (SAI) alone or components of the index provide a better explanatory model for self-care and diabetes outcomes. Six hundred fifteen patients were recruited from two primary care settings. A series of multiple linear regression models were run to assess (1) associations between the SAI and diabetes self-care/outcomes, and (2) associations between individual SAI indicator variables and diabetes self-care/outcomes. Separate models were run for each self-care behavior and outcome. Two models were run for each dependent variable to compare associations with the SAI and components of the index. The SAI has a significant association with the mental component of quality of life (0.23, p < 0.01). In adjusted analyses, the SAI score did not have a significant association with any of the self-care behaviors. Individual components from the index had significant associations between self-care and multiple SAI indicator variables. Significant associations also exist between outcomes and the individual SAI indicators for education and employment. In this population, the SAI has low explanatory power and few significant associations with diabetes self-care/outcomes. While the use of a composite index to predict outcomes within a diabetes population would have high utility, particularly for clinical settings, this SAI lacks statistical and clinical significance in a representative diabetes population. Based on these results, the index does not provide a good model fit and masks the relationship of individual components to diabetes self-care and outcomes. These findings suggest that five items alone are not adequate to explain or predict outcomes for patients with type 2 diabetes.

Pediatric Diabetes Telemedicine Program Improves Access to Care for Rural Families: Role of APRNs.

PubMed

Smith, Nancy Marie; Satyshur, Rosemarie DiMauro

2016-01-01

Type 1 diabetes mellitus has increased in children by 23% from 2001 to 2009. Rural communities additionally have increased disparities related to access barriers and a large minority population with poorer overall health. Research evidence supports telemedicine as an effective alternative to bring preventive diabetes care to remote areas. This article presents an overview of the leadership role of advanced practice registered nurses (APRNs) with the implementation and evaluation of a pediatric diabetes telemedicine program at a rural pediatric outpatient specialty clinic in partnership with a tertiary center telemedicine network. The telemedicine program quality improvement (QI) project explored caregiver satisfaction with a convenience sample of caregivers (N = 14) using a nine-item Telemedicine Diabetes Caregiver Satisfaction Survey (TDCSS), with responses ranging from 1 = strongly disagree to 5 = strongly agree. Findings indicate caregivers were highly satisfied with communication/ privacy (M = 4.8), access to care (M = 4.1), and quality of services (M = 5.0). The multidisciplinary collaborative teamwork, continuous QI, and dependable technology were integral to the quality of the telemedicine clinical initiative. APRNs provided technology expertise, interdisciplinary collaboration leadership, care coordination, and advocacy for policy changes. Results demonstrate that telemedicine and APRN leadership can help implement innovative programs into rural communities to improve access to care, healthcare cost, and outcomes.

Asynchronous and Synchronous Teleconsultation for Diabetes Care: A Systematic Literature Review

PubMed Central

Verhoeven, Fenne; Tanja-Dijkstra, Karin; Nijland, Nicol; Eysenbach, Gunther; van Gemert-Pijnen, Lisette

2010-01-01

Aim A systematic literature review, covering publications from 1994 to 2009, was carried out to determine the effects of teleconsultation regarding clinical, behavioral, and care coordination outcomes of diabetes care compared to usual care. Two types of teleconsultation were distinguished: (1) asynchronous teleconsultation for monitoring and delivering feedback via email and cell phone, automated messaging systems, or other equipment without face-to-face contact; and (2) synchronous teleconsultation that involves real-time, face-to-face contact (image and voice) via videoconferencing equipment (television, digital camera, webcam, videophone, etc.) to connect caregivers and one or more patients simultaneously, e.g., for the purpose of education. Methods Electronic databases were searched for relevant publications about asynchronous and synchronous tele-consultation [Medline, Picarta, Psychinfo, ScienceDirect, Telemedicine Information Exchange, Institute for Scientific Information Web of Science, Google Scholar]. Reference lists of identified publications were hand searched. The contribution to diabetes care was examined for clinical outcomes [e.g., hemoglobin A1c (HbA1c), dietary values, blood pressure, quality of life], for behavioral outcomes (patient-caregiver interaction, self-care), and for care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of access to care). Randomized controlled trials with HbA1c as an outcome were pooled using standard meta-analytical methods. Results Of 2060 publications identified, 90 met inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1 and 2 or gestational diabetes. Studies that evaluated teleconsultation not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (e.g., HbA1c or lipid profiles). In 63 of 90 interventions, the interaction had an

Perceptions on diabetes care provision among health providers in rural Tanzania: a qualitative study

PubMed Central

Geubbels, Eveline; Klatser, Paul; Dieleman, Marjolein

2017-01-01

Abstract Diabetes prevalence in Tanzania was estimated at 9.1% in 2012 among adults aged 24–65 years — higher than the HIV prevalence in the general population at that time. Health systems in lower- and middle-income countries are not designed for chronic health care, yet the rising burden of non-communicable diseases such as diabetes demands chronic care services. To inform policies on diabetes care, we conducted a study on the health services in place to diagnose, treat and care for diabetes patients in rural Tanzania. The study was an exploratory and descriptive study involving qualitative methods (in-depth interviews, observations and document reviews) and was conducted in a rural district in Tanzania. Fifteen health providers in four health facilities at different levels of the health care system were interviewed. The health care organization elements of the Innovative Care for Chronic Conditions (ICCC) framework were used to guide assessment of the diabetes services in the district. We found that diabetes care in this district was centralized at the referral and district facilities, with unreliable supply of necessary commodities for diabetes care and health providers who had some knowledge of what was expected of them but felt ill-prepared for diabetes care. Facility and district level guidance was lacking and the continuity of care was broken within and between facilities. The HMIS could not produce reliable data on diabetes. Support for self-management to patients and their families was weak at all levels. In conclusion, the rural district we studied did not provide diabetes care close to the patients. Guidance on diabetes service provision and human resource management need strengthening and policies related to task-shifting need adjustment to improve quality of service provision for diabetes patients in rural settings. PMID:27935802

Assessment of the quality of primary care for the elderly according to the Chronic Care Model 1

PubMed Central

Silva, Líliam Barbosa; Soares, Sônia Maria; Silva, Patrícia Aparecida Barbosa; Santos, Joseph Fabiano Guimarães; Miranda, Lívia Carvalho Viana; Santos, Raquel Melgaço

2018-01-01

ABSTRACT Objective: to evaluate the quality of care provided to older people with diabetes mellitus and/or hypertension in the Primary Health Care (PHC) according to the Chronic Care Model (CCM) and identify associations with care outcomes. Method: cross-sectional study involving 105 older people with diabetes mellitus and/or hypertension. The Patient Assessment of Chronic Illness Care (PACIC) questionnaire was used to evaluate the quality of care. The total score was compared with care outcomes that included biochemical parameters, body mass index, pressure levels and quality of life. Data analysis was based on descriptive statistics and multiple logistic regression. Results: there was a predominance of females and a median age of 72 years. The median PACIC score was 1.55 (IQ 1.30-2.20). Among the PACIC dimensions, the “delivery system design/decision support” was the one that presented the best result. There was no statistical difference between the medians of the overall PACIC score and individual care outcomes. However, when the quality of life and health satisfaction were simultaneously evaluated, a statistical difference between the medians was observed. Conclusion: the low PACIC scores found indicate that chronic care according to the CCM in the PHC seems still to fall short of its assumptions. PMID:29538582

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014.

PubMed

Tran, Anh Thi; Bakke, Åsne; Berg, Tore J; Gjelsvik, Bjørn; Mdala, Ibrahimu; Nøkleby, Kjersti; Shakil Rai, Anam; Cooper, John G; Claudi, Tor; Løvaas, Karianne; Thue, Geir; Sandberg, Sverre; Jenum, Anne K

2018-06-01

To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM). Cross-sectional survey. The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified. Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics. Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p < 0.01), a larger proportion of their patients achieved good glycaemic control (HbA1c = 6.0%-7.0%) (49.1% vs. 44.4%, p = 0.018) and lower mean systolic blood pressure (133.0 mmHg vs. 134.7 mmHg, p < 0.01) compared with non-specialists. GPs who graduated in Western Europe achieved lower diastolic blood pressure than their counterparts (76.6 mmHg vs. 77.8 mmHg, p < 0.01). Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice. Key Points Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited. Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists. GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower

Contributors to Patients' Ratings of Quality of Care Among Ethnically Diverse Patients with Type 2 Diabetes.

PubMed

Choi, Sarah E; Ngo-Metzger, Quyen; Billimek, John; Greenfield, Sheldon; Kaplan, Sherrie H; Sorkin, Dara H

2016-04-01

We examined racial/ethnic differences in patients' ratings of components of interpersonal quality [participatory decision making (PDM) style, being treated as an equal partner, and feelings of trust], and evaluated the association between each of these components and patients' ratings of overall healthcare quality among non-Hispanic white (NHW), Vietnamese American, and Mexican American patients with type 2 diabetes. The findings indicated that although all three components were significantly associated with ratings of overall healthcare quality, the significant interactions between race/ethnicity and both PDM style (β = -0.09, p < 0.01) and equal partner (β = -0.06, p < 0.05) for the Vietnamese American patients suggested that the relationship between these components and patients' ratings of healthcare quality were less strong among Vietnamese American patients than among the NHW patients. Understanding racial/ethnic differences in the components of interpersonal quality that are associated with patients' ratings of overall healthcare quality is an important step for improving patients' experiences of their own care.

Diabetes Mellitus Standards of Care.

PubMed

Mays, Lucy

2015-12-01

Diabetes is a worldwide epidemic with a high cost regarding consumption of health care resources and is associated with high levels of morbidity and mortality. The complex nature of diabetes requires the use of evidence-based guidelines regarding diabetes management. These evidence-based guidelines are lengthy and do not readily translate into nursing care. As an integral component of the interprofessional team, the nurse must provide a thorough assessment of patients with diabetes and work to achieve individual patient treatment goals. Evaluation of patient progress toward treatment goals with regular/frequent follow-up is necessary to promote effective self-management of diabetes. Copyright © 2015 Elsevier Inc. All rights reserved.

Diabetes: Guidelines of Care for Children with Special Health Care Needs.

ERIC Educational Resources Information Center

Minnesota State Dept. of Health, Minneapolis. Services for Children with Handicaps.

This booklet contains guidelines to help families coordinate health care of a child with diabetes. The first section provides general information covering what diabetes mellitus-Type I is, the symptoms of diabetes, causes of Type I diabetes, and effects of diabetes. A section on health care focuses on the membership and functions of the Family…

Performance-based financial incentives for diabetes care: an effective strategy?

PubMed

Latham, Lesley P; Marshall, Emily Gard

2015-02-01

The use of financial incentives provided to primary care physicians who achieve target management or clinical outcomes has been advocated to support the fulfillment of care recommendations for patients with diabetes. This article explores the characteristics of incentive models implemented in the context of universal healthcare systems in the United Kingdom, Australia, Taiwan and Canada; the extent to which these interventions have been successful in improving diabetes outcomes; and the key challenges and concerns around implementing incentive models. Research in the effect of incentives in the United Kingdom demonstrates some improvements in process outcomes and achievement of cholesterol, blood pressure and glycated hemoglobin (A1C) targets. Evidence of the efficacy of programs implemented outside of the United Kingdom is very limited but suggests that physicians participating in these enhanced billing incentive programs were already completing the guideline-recommended care prior to the introduction of the incentive. A shift to pay-for-performance programs may have important implications for professionalism and patient-centred care. In the absence of definitive evidence that financial incentives drive the quality of diabetes management at the level of primary care, policy makers should proceed with caution. It is important to look beyond simply modifying physicians' behaviours and address the factors and systemic barriers that make it challenging for patients and physicians to manage diabetes in partnership. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Evaluation of patients' education on foot self-care status in diabetic patients.

PubMed

Kafaie, Parichehr; Noorbala, Mohamad Taghi; Soheilikhah, Sedigheh; Rashidi, Maryam

2012-12-01

Skin problems caused by neuropathy and antipathy are common manifestations of diabetes. The most serious about such problem is the diabetic foot, which may lead to eventual ulceration and amputation, and will decrease a patient's quality of life dramatically. The aim of this study is to assess the level of foot self-care and foot conditions in diabetic patients, and to demonstrate the role of self-care education in diabetic foot care. A total of 80 diabetic patients were included in the study, all of whom had referred to "Yazd Diabetic Research Center." The levels of their foot self-care were recorded in pre-test questionnaires, and then all of the patients were visited and educated by a Dermatologist for their foot self-care on a monthly basis, after which their post-test results were recorded through a second administration of the same questionnaire. Eventually, data from the pre and post-test questionnaires were analyzed to identify the possible effects of education. A total of 80 diabetic patients (34 males, 46 females) with a mean average age of 53.53 ± 10.19 and mean average duration of diabetes 12.42 ± 6.73 years were assessed. A significant increase in foot self-care through education was observed (baseline 27.06 ± 8.77, vs. post education 43.12 ± 8.77; P = 0.0001). After education, foot and nail lesions improved completely in 84% and 62.8%. Moreover, 77.8% of patients had suitable shoes and 79.6% had suitable socks. Our findings showed that foot self-care education could improve knowledge and performance of patients about various foot problems, and was significantly important in preventing ulcers.

Perceived unsatisfactory care as a barrier to diabetes self-management for Coeur d'Alene tribal members with type 2 diabetes.

PubMed

Tiedt, Jane A; Sloan, Rebecca S

2015-05-01

The prevalence of diabetes and related complications are disproportionally higher in Native Americans. Diabetes self-management (DSM) is instrumental in preventing complications. The results presented here are a part of a larger hermeneutic phenomenology study to explore living with diabetes for one Pacific Northwest tribe. This study identified barriers to DSM within the worldview of the tribal people. Using purposive sampling, 10 Coeur d'Alene tribal members, ages 26 to 86 years, participated in in-depth interviews. Data interpretation used a three-step method leading to integrated themes across the transcripts. Perceived unsatisfactory care emerged as the major barrier to self-management, including communication barriers (distrust, misunderstanding, and educational methods) and organizational barriers (quality of care and access issues). Findings highlight the need to improve cross-cultural communication and calls for different approaches to diabetes education. Our profession is challenged to create new DSM and diabetes educational approaches for acceptable and compassionate cross-cultural nursing care. © The Author(s) 2014.

Family Medicine Panel Size with Care Teams: Impact on Quality.

PubMed

Angstman, Kurt B; Horn, Jennifer L; Bernard, Matthew E; Kresin, Molly M; Klavetter, Eric W; Maxson, Julie; Willis, Floyd B; Grover, Michael L; Bryan, Michael J; Thacher, Tom D

2016-01-01

The demand for comprehensive primary health care continues to expand. The development of team-based practice allows for improved capacity within a collective, collaborative environment. Our hypothesis was to determine the relationship between panel size and access, quality, patient satisfaction, and cost in a large family medicine group practice using a team-based care model. Data were retrospectively collected from 36 family physicians and included total panel size of patients, percentage of time spent on patient care, cost of care, access metrics, diabetic quality metrics, patient satisfaction surveys, and patient care complexity scores. We used linear regression analysis to assess the relationship between adjusted physician panel size, panel complexity, and outcomes. The third available appointments (P < .01) and diabetic quality (P = .03) were negatively affected by increased panel size. Patient satisfaction, cost, and percentage fill rate were not affected by panel size. A physician-adjusted panel size larger than the current mean (2959 patients) was associated with a greater likelihood of poor-quality rankings (≤25th percentile) compared with those with a less than average panel size (odds ratio [OR], 7.61; 95% confidence interval [CI], 1.13-51.46). Increased panel size was associated with a longer time to the third available appointment (OR, 10.9; 95% CI, 1.36-87.26) compared with physicians with panel sizes smaller than the mean. We demonstrated a negative impact of larger panel size on diabetic quality results and available appointment access. Evaluation of a family medicine practice parameters while controlling for panel size and patient complexity may help determine the optimal panel size for a practice. © Copyright 2016 by the American Board of Family Medicine.

Responsive parenting is associated with improved type 1 diabetes-related quality of life

PubMed Central

Botello-Harbaum, Maria; Nansel, Tonja; Haynie, Denise; Iannotti, Ronald J.; Simons-Morton, Bruce

2008-01-01

Background Improved quality of life is an important treatment goal for children and adolescents with type 1 diabetes. While previous research supports a relationship between family environment and quality of life, little research has addressed the relationship of parenting style constructs to quality of life in children with chronic disease. The present investigation assesses the relationship of parent responsiveness and demandingness with diabetes-related quality of life among children and adolescents with type 1 diabetes. Methods Baseline and 12-month follow-up self-report assessments were collected on a sample of 81 children with type 1 diabetes participating in an efficacy trial of a behavioral intervention to enhance adherence. The sample had a mean age of 13.3 years (SD = 1.7) and duration of diabetes of 7.7 years (SD = 3.7). Multiple regression analyses were conducted to determine the relationship of parent responsiveness and demandingness to diabetes-related quality of life at each time point. Results After adjusting for demographic and diabetes characteristics, as well as diabetes-specific parent-child behaviors, parent responsiveness was significantly associated with baseline diabetes-related quality of life (B=.23; p=.04). This relationship was sustained at 12-month follow-up (B=.22; p=.04) after adjusting for baseline quality of life and treatment group assignment, suggesting that parent responsiveness is associated with improved quality of life. Conclusions Findings indicate the importance of a supportive and emotionally warm parenting style in promoting improved quality of life for children with type 1 diabetes. Appropriate parenting skills should be an element of diabetes family management health care. PMID:18796059

The quality of primary care provided to the elderly in Israel.

PubMed

Podell, Rachel; Shriqui, Vered Kaufman; Sagy, Yael Wolff; Manor, Orly; Ben-Yehuda, Arie

2018-06-04

In view of increasing global and local trends in population ageing and the high healthcare utilization rates among the elderly, this study assesses the quality of primary care provided to the elderly population in Israel. It examines changes in quality over time, how quality varies across sub-groups of the elderly, and how quality in Israel compares with other countries. Data originate from the National Program for Quality Indicators in Community Healthcare (QICH), which operates in full collaboration with Israel's four HMOs. The study population included all elderly Israeli residents aged 65 years or older during 2002-2015 (N = 879,671 residents in 2015). Seven elderly-specific quality indicators from within the QICH framework were included: influenza and pneumococcal vaccinations, benzodiazepine overuse, long-acting benzodiazepine use, body weight documentation, weight loss and underweight. In addition, two non-age specific quality indicators relating to diabetes mellitus were included: the rate of HbA1C documentation and uncontrolled diabetes. Data were collected from patient electronic medical records (EMR) in accordance with each HMO, and aggregated by three variables: gender, age, and socio-economic position (SEP). During the measurement period, vaccination rates significantly increased (Influenza: from 42.0% in 2002 to 63.2% in 2015; and pneumococcal vaccination: from 25.8% in 2005 to 77.0% in 2015). Body weight documentation (in 65-74 year old persons) increased from only 16.3% in 2003 to 80.9% in 2015. The rate of underweight (BMI < 23 kg/m 2 ) and significant weight-loss (10% or more of their body weight) was only measured in 2015. The overall rate of benzodiazepine overuse remained steady from 2011 to 2015 at around 5%, while the rate of long-acting benzodiazepine use decreased from 3.8% in 2011 to 2.4% in 2015. The rate of HbA1c documentation for elderly diabetics was higher than for non-elderly diabetics in 2015 (92.2% vs 87.9%). The rate of

Diabetes care and control: the effect of frequent visits to diabetes care center.

PubMed

Al, Omar Mansour

2014-01-01

Frequent visits to diabetes care clinics linked with better control of diabetes mellitus (DM), but debates exist about how frequently visits should be done. The objective of this study was to assess the effect of frequent visits on diabetes care and control. A prospective study of 100 diabetic patients attending Prince Abdul-Aziz Bin-Majed Diabetes Care Centre (PAMDCC), Al Madinah Al Munawwarah, Saudi Arabia, during the period from March 2011 through December 2012. Demographics, lifestyle, and diabetes data were obtained at the index visit. At that and subsequent visits, glycosated hemoglobin (HBA1c), blood pressure (BP) and low-density lipoprotein (LDL) were measured. All these data together with visit number and gap were recorded. Statistical analysis including linear regression analysis was done. A significant reduction in the mean of diabetic control parameters was observed at the last visit. The highest mean changes were observed in patients with > 6 visits, visit gap =8. Adjusted linear regression showed that each visit significantly lowered HBA1c by 0.25%, BP by 2.1/0.7 mm Hg and 0.2 mmol/L for LDL. The number of visits needed to get HBA1c < 7% and BP < 130/85 was 8 and 5 visits with a visit-month index of 14 and 5, respectively. The study suggests that frequent visits at short intervals may lead to better diabetes control. Other prospective clinical trial studies are needed to confirm these findings and to outline the appropriate cost-effective intervals and visit gaps.

Organization of primary health care for diabetes and hypertension in high, low and middle income countries.

PubMed

Lall, Dorothy; Prabhakaran, Dorairaj

2014-08-01

Chronic non-communicable diseases, predominantly diabetes and cardiovascular disease are a major public health problem globally. The chronicity of these diseases necessitates a restructuring of healthcare to address the multidisciplinary, sustained care including psychosocial support and development of self-management skills. Primary healthcare with elements of the chronic-care model provides the best opportunity for engagement with the health system. In this review, the authors discuss aspects of primary healthcare for management of diabetes and hypertension and innovations such as mobile-phone messaging, web-based registries, computer-based decision support systems and multifaceted health professionals in the care team among others that are being tested to improve the quality of care for these diseases in high, middle and low-income countries. The goal of quality care for diabetes and hypertension demands innovation within the realities of health systems both in high as well as low and middle-income countries.

An innovative model of diabetes care and delivery: the St. Joseph's Primary Care Diabetes Support Program (SJHC PCDSP).

PubMed

Reichert, Sonja M; Harris, Stewart; Harvey, Betty

2014-06-01

The majority of diabetes care in Canada is provided within the primary healthcare setting. It is delivered in a variety of models ranging from the physician working in a solo fee-for-service practice to an interprofessional team setting with specialist collaboration. To augment diabetes-related health services, the Ontario government has provided substantial funding to support community diabetes education programs. These models and initiatives are improving diabetes outcomes, and continued evolution of these programs can provide even greater outcomes. The St. Joseph's Primary Care Diabetes Support Program (SJHC PCDSP) is an innovative model that incorporates multidisciplinary allied health professionals together with physician support to provide care for more than 3000 patients in London, Ontario, Canada. It embodies the Canadian Diabetes Association (CDA)'s Organizations of Care recommendations to combine patient education and self-management with active medical support at each clinic encounter, all while embodying the tenets of primary care. A brief review of primary healthcare reform is provided to explain how the SJHC PCDSP combines features of current models in a unique format so as to deliver exceptional patient care. By providing a detailed description of the services delivered at the SJHC PCDSP, it is hoped that both specialists and primary care providers consider using and adapting approaches to diabetes management based on this innovative model to optimize their practices. Copyright © 2014 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Impact of socio-economic position on health and quality of care in adults with Type 2 diabetes in France: the Entred 2007 study.

PubMed

Fosse-Edorh, S; Fagot-Campagna, A; Detournay, B; Bihan, H; Eschwege, E; Gautier, A; Druet, C

2015-11-01

To describe the association between socio-economic position, health status and quality of diabetes care in people with Type 2 diabetes in France, where people may receive full healthcare coverage for chronic disease. Data from a national cross-sectional survey performed in people pharmacologically treated for diabetes were used. They combined data from medical claims, hospital discharge, questionnaires for patients (n = 3894 with Type 2 diabetes) and their physicians (n = 2485). Socio-economic position was assessed using educational level (low, intermediate, high) and ability to make ends meet (financial difficulties vs. financially comfortable). People with diabetes reporting financial difficulties were more likely to be smokers (adjusted odds ratio 1.4; 95% CI 1.1-1.6) and obese (adjusted odds ratio 1.3; 95% CI 1.2-1.6) and to have poorer glycaemic control (HbA1c > 64 mmol/mol (8%); adjusted odds ratio 1.4; 95% CI 1.1-1.8), than those who were financially comfortable. They were more likely to have their diabetes diagnosed because of complications (adjusted odds ratio 1.6; 95% CI 1.3-2.0). They were also more likely to have coronary and podiatric complications (adjusted odds ratios 1.3; 95% CI 1.1-1.6 and 1.7; 95% CI 1.4-2.2, respectively). They benefited more often from full coverage (adjusted odds ratio 1.3; 95% CI 1.1-1.6), visited general practitioners more often (ratio of estimated marginal means 1.2; 95% CI 1.1-1.2) but specialists less often (adjusted odds ratio 0.7; 95% CI 0.6-0.8 for a visit to private ophthalmologist). They also felt less well informed about their condition. Despite frequent access to full healthcare coverage, socio-economic position has an impact on the diagnosis of diabetes, health status and quality of diabetes care in France. © 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.

Design and implementation of a web-based patient portal linked to an ambulatory care electronic health record: patient gateway for diabetes collaborative care.

PubMed

Grant, Richard W; Wald, Jonathan S; Poon, Eric G; Schnipper, Jeffrey L; Gandhi, Tejal K; Volk, Lynn A; Middleton, Blackford

2006-10-01

Despite the availability of expert guidelines and widespread diabetes quality improvement efforts, care of patients with diabetes remains suboptimal. Two key barriers to care that may be amenable to informatics-based interventions include (1) lack of patient engagement with therapeutic care plans and (2) lack of medication adjustment by physicians ("clinical inertia") during clinical encounters. The authors describe the conceptual framework, design, implementation, and analysis plan for a diabetes patient web-portal linked directly to the electronic health record (EHR) of a large academic medical center via secure Internet access designed to overcome barriers to effective diabetes care. Partners HealthCare System (Boston, MA), a multi-hospital health care network comprising several thousand physicians caring for over 1 million individual patients, has developed a comprehensive patient web-portal called Patient Gateway that allows patients to interact directly with their EHR via secure Internet access. Using this portal, a specific diabetes interface was designed to maximize patient engagement by importing the patient's current clinical data in an educational format, providing patient-tailored decision support, and enabling the patient to author a "Diabetes Care Plan." The physician view of the patient's Diabetes Care Plan was designed to be concise and to fit into typical EHR clinical workflow. We successfully designed and implemented a Diabetes Patient portal that allows direct interaction with our system's EHR. We are assessing the impact of this advanced informatics tool for collaborative diabetes care in a clinic-randomized controlled trial among 14 primary care practices within our integrated health care system.

The Affordable Care Act and Diabetes Diagnosis and Care: Exploring the Potential Impacts

PubMed Central

Laiteerapong, Neda

2016-01-01

This article reviews available data on the implications of the Affordable Care Act (ACA) for the diagnosis and care of type 2 diabetes. We provide a general overview of the major issues for diabetes diagnosis and care, and describe the policies in the ACA that affect diabetes diagnosis and care. We also estimate that approximately 2.3 million of the 4.6 million people in the USA with undiagnosed diabetes aged 18–64 in 2009–2010 may have gained access to free preventive care under the ACA, which could increase diabetes detection. In addition, we note two factors that may limit the success of the ACA for improving access to diabetes care. First, many states with the highest diabetes prevalence have not expanded Medicaid eligibility, and second, primary care providers may not adequately meet the increase in Medicaid patients because federal funding to increase provider reimbursement for Medicaid visits recently expired. We close by discussing current gaps in the literature and future directions for research on the ACA’s impact on diabetes diagnosis, care, and health outcomes. PMID:26892908

Evaluating quality of care for patients with type 2 diabetes using electronic health record information in Mexico

PubMed Central

2012-01-01

Background Several low and middle-income countries are implementing electronic health records (EHR). In the near future, EHRs could become an efficient tool to evaluate healthcare performance if appropriate indicators are developed. The aims of this study are: a) to develop quality of care indicators (QCIs) for type 2 diabetes (T2DM) in the Mexican Institute of Social Security (IMSS) health system; b) to determine the feasibility of constructing QCIs using the IMSS EHR data; and c) to evaluate the quality of care (QC) provided to IMSS patients with T2DM. Methods We used a three-stage mixed methods approach: a) development of QCIs following the RAND-UCLA method; b) EHR data extraction and construction of indicators; c) QC evaluation using EHR data from 25,130 T2DM patients who received care in 2009. Results We developed 18 QCIs, of which 14 were possible to construct using available EHR data. QCIs comprised both process of care and health outcomes. Several flaws in the EHR design and quality of data were identified. The indicators of process and outcomes of care suggested areas for improvement. For example, only 13.0% of patients were referred to an ophthalmologist; 3.9% received nutritional counseling; 63.2% of overweight/obese patients were prescribed metformin, and only 23% had HbA1c <7% (or plasma glucose ≤130 mg/dl). Conclusions EHR data can be used to evaluate QC. The results identified both strengths and weaknesses in the electronic information system as well as in the process and outcomes of T2DM care at IMSS. This information can be used to guide targeted interventions to improve QC. PMID:22672471

Brief report: glycemic control, quality of life, and school experiences among students with diabetes.

PubMed

Wagner, Julie; Heapy, Alicia; James, Amy; Abbott, Gina

2006-09-01

To investigate the relationships among perceived school experiences, diabetes control, and quality of life (QOL) in children with diabetes. Fifty-eight children with type 1 diabetes and their parents participated. The typical child was 12 years old, had diabetes for 5 years, and attended public, suburban, middle/junior high schools with 300-500 students. Children whose parents reported that school personnel received diabetes training showed significantly better diabetes control than those who reported untrained school personnel. Children who reported their classmates received diabetes training had significantly better QOL than those who reported untrained classmates. Children who reported greater flexibility in performing diabetes care tasks at school had significantly better diabetes control than children who reported less flexibility. Students with diabetes continue to face challenges at school. Training staff and classmates and allowing students the maximum appropriate flexibility in diabetes care appears beneficial for disease control and QOL.

Improving the Quality of Outpatient Diabetes Care Using an Information Management System

PubMed Central

Weissmann, Joerg; Mueller, Angelika; Messinger, Diethelm; Parkin, Christopher G.; Amann-Zalan, Ildiko

2015-01-01

Background: This study aimed to evaluate the effects of information management system (IMS) use with individuals with type 1 and type 2 diabetes who were treated in outpatient settings. Methods: In this 7-month, prospective, observational study, 965 adults with diabetes, mean (SD) baseline HbA1c 8.61(1.2)% (70.6[13.1] mmol/mol), were recruited from 132 outpatient care centers in Germany and Denmark. HbA1c was measured at baseline, month 4, and month 7. IMS reports were generated from uploaded self-monitored blood glucose data and therapy adjustments were documented at months 1 and 4. Hypoglycemic events were documented. Results: Mean (SD) HbA1c decreased from baseline in type 1 and type 2 diabetes patients at month 4 (–0.61[1.03]% (–6.7[11.3] mmol/mol), n = 213; –0.88[1.22]% (–9.6[13.3] mmol/mol), n = 589, respectively) and month 7 (–0.64[1.02]% (–7.0[11.1] mmol/mol), n = 219; –0.93[1.27]% (–10.2[13.9] mmol/mol), n = 594, respectively), all P < .0001, with no increase in hypoglycemic events. Therapy was adjusted in 106(42.7)% type 1 and 349(52.4)% type 2 diabetes patients at months 1 and 105(42.3)% type 1 and 282(42.3)% type 2 diabetes patients at month 4. Physicians used IMS reports to make therapy adjustments in 90% of patients at month 1 and 86% of patients at month 4. Conclusions: Integration of the IMS into outpatient care facilitates significant improvements in glycemic control. PMID:26224760

A national approach to diabetes foot risk stratification and foot care.

PubMed

Leese, G P; Stang, D; Pearson, D W

2011-08-01

The Scottish Diabetes Foot Action Group (SDG) has developed and introduced a national strategy plan for diabetic foot care across Scotland. This has involved the implementation of an evidence-based national foot screening and risk stratification programme that has already covered 61% of the population in just the first two years. Nationally agreed patient information foot leaflets and professional education material have been introduced, and a consensus for antibiotic use in the diabetic foot has been published. Information on multidisciplinary specialist foot services has been collected, indicating that 58% of Health Board areas have consultants with dedicated sessions in their job plan to a foot clinic, and 42% had integrated orthotic involvement. The SDG aims to increase these figures. Work has been undertaken to support local podiatry networks and improve communication between the specialist centre and the community. At a national level the SDG is working with Foot in Diabetes UK (FDUK) to recognize key podiatry skills by developing core competencies and a competency framework for the diabetes podiatrist and diabetes orthotist. The annual Scottish Diabetes Survey indicates some improvement in amputation rates with prevalence decreasing from 0.8% to 0.5%, and improved recording of foot ulceration at a national level. This national strategy has helped highlight the importance and difficulties facing diabetes foot care and should help to continue to improve the quality of care of people with diabetes who have foot-related problems.

Making sense of change: patients' views of diabetes and GP-led integrated diabetes care.

PubMed

Burridge, Letitia H; Foster, Michele M; Donald, Maria; Zhang, Jianzhen; Russell, Anthony W; Jackson, Claire L

2016-02-01

Health system reform is directed towards better management of diabetes. However, change can be difficult, and patients' perspectives are a key aspect of implementing change. This study investigated patients' perceptions and experiences of type 2 diabetes (T2DM), self-care and engagement with GP-led integrated diabetes care. Qualitative interviews were conducted with purposively selected patients with T2DM following their initial medical appointment in the new model of care. Normalization process theory was used to orientate the thematic analysis, to explain the work of implementing change. Two specialist GP-based complex diabetes services in primary care in Brisbane, Australia. Intervention group patients (n = 30) in a randomized controlled trial to evaluate a model of GP-led integrated care for complex T2DM. Participants' experiences and perceptions of diabetes management and a GP-led model of care. Three themes were identified: sensibility of change, 'diabetic life' and diabetes care alliance. The imperative of change made sense, but some participants experienced dissonance between this rational view and their lived reality. Diabetes invaded life, revealing incongruities between participants' values and living with diabetes. They appreciated a flexible and personalized approach to care. Participants responded to advice in ways that seemed rational within the complexities of their life context. Their diabetes partnerships with health professionals coupled providers' biomedical expertise with patients' contextual expertise. Learning to manage relationships with various health professionals adds to patients' diabetes-related work. Providers need to adopt a flexible, interactive approach and foster trust, to enable better diabetes care. © 2015 John Wiley & Sons Ltd.

Taking Care of Your Diabetes Means Taking Care of Your Heart (Tip Sheet)

MedlinePlus

... Diabetes Means Taking Care of Your Heart Taking Care of Your Diabetes Means Taking Care of Your Heart Diabetes and Heart Disease For ... What you can do now Ask your health care team these questions: What can I do to ...

Impact of office systems and improvement strategies on costs of care for adults with diabetes.

PubMed

Gilmer, Todd P; O'Connor, Patrick J; Rush, William A; Crain, A Lauren; Whitebird, Robin R; Hanson, Anne M; Solberg, Leif I

2006-06-01

To assess the impact of organizational features and improvement strategies of primary care clinics on health care costs of adults with diabetes. This study included a prospective cohort study of 1,628 adults with diabetes in a large, health care organization receiving care in 84 clinics within 18 medical groups. Data from surveys of patients, clinic medical directors and managers, and medical record reviews were merged with 3 years of medical claims. Costs were estimated using health plan data on resource use and common Medicare payment methodologies. Generalized linear regression models were used to analyze costs related to clinic characteristics, adjusting for individual patient comorbidity, demographic, and socioeconomic factors. Clinics with regular clinician meetings to discuss patient care problems and clinics that used diabetes registries to prioritize patients based on cardiovascular risk were associated with lower 3-year costs: -$3,962 (P = 0.002) and -$2,916 (P = 0.019), respectively. The use of databases to monitor lab results was associated with higher costs ($2,439, P = 0.038). Quality improvement strategies focused on resource use related to diabetes care (-$2,883, P = 0.017) or heart disease care (-$3,228, P = 0.014) were associated with lowered costs, whereas quality improvement strategies that emphasized pharmacy use for patients with heart disease ($3,059, P = 0.029) or depression ($2,962, P = 0.038) were associated with increased costs. Several organizational features of primary care offices were significant predictors of future health care costs for adults with diabetes. The mechanism by which such factors affect costs of care and the relationship of costs to clinical outcomes merits further evaluation.

Costs, outcomes and challenges for diabetes care in Spain

PubMed Central

2013-01-01

Background Diabetes is becoming of increasing concern in Spain due to rising incidence and prevalence, although little information is known with regards to costs and outcomes. The information on cost of diabetes in Spain is fragmented and outdated. Our objective is to update diabetes costs, and to identify outcomes and quality of care of diabetes in Spain. Methods We performed systematic searches from secondary sources, including scientific literature and government data and reports. Results Diabetes Type II prevalence is estimated at 7.8%, and an additional 6% of the population is estimated to be undiagnosed. Four Spanish diabetes cost studies were analyzed to create a projection of direct costs in the NHS and productivity losses, estimating €5.1 billion for direct costs along with €1.5 billion for diabetes-related complications (2009) and labour productivity losses represented €2.8 billion. Glycemic control (glycolysated hemoglobin) is considered acceptable in 59% of adult Type II cases, in addition to 85% with HDL cholesterol ≥40mg/dl and 65% with blood pressure <140/90 mmHg, pointing to good intermediate outcomes. However, annual figures indicate that over half of the Type II diabetics are obese (BMI >30), 15% have diabetic retinopathy, 16% with microalbuminuria, and 15% with cardiovascular disease. Conclusions The direct health care costs (8% of the total National Health System expenditure) and the loss of labour productivity are high. The importance of a multi-sectoral approach in prevention and improvements in management of diabetes are discussed, along with policy considerations to help modify the disease course. PMID:23635075

Clinic Workload, the Quality of Staff Relationships and Diabetes Management in Community Health Centers Catering to Latino and Chinese Patients.

PubMed

Vargas Bustamante, Arturo; Martinez, Ana; Chen, Xiao; Rodriguez, Hector P

2017-06-01

We examine whether workplace climate-quality of staff relationships (QSR) and manageable clinic workload (MCW) are related to better patient care experiences and diabetes care in community health centers (CHCs) catering to Latino and Chinese patients. Patient experience surveys of adult patients with type 2 diabetes and workplace climate surveys of clinicians and staff from CHCs were included in an analytic sample. Comparisons of means analyses examine patient and provider characteristics. The associations of QSR, MCW and the diabetes care management were examined using regression analyses. Diabetes care process were more consistently provided in CHCs with high quality staff relations and more manageable clinic workload, but HbA1c, LDL cholesterol, and blood pressure outcomes were no different between clinics with high vs. low QSR and MCW. Focusing efforts on improvements in practice climate may lead to more consistent provision of important processes of diabetes care for these patients.

Comparing clinical automated, medical record, and hybrid data sources for diabetes quality measures.

PubMed

Kerr, Eve A; Smith, Dylan M; Hogan, Mary M; Krein, Sarah L; Pogach, Leonard; Hofer, Timothy P; Hayward, Rodney A

2002-10-01

Little is known about the relative reliability of medical record and clinical automated data, sources commonly used to assess diabetes quality of care. The agreement between diabetes quality measures constructed from clinical automated versus medical record data sources was compared, and the performance of hybrid measures derived from a combination of the two data sources was examined. Medical records were abstracted for 1,032 patients with diabetes who received care from 21 facilities in 4 Veterans Integrated Service Networks. Automated data were obtained from a central Veterans Health Administration diabetes registry containing information on laboratory tests and medication use. Success rates were higher for process measures derived from medical record data than from automated data, but no substantial differences among data sources were found for the intermediate outcome measures. Agreement for measures derived from the medical record compared with automated data was moderate for process measures but high for intermediate outcome measures. Hybrid measures yielded success rates similar to those of medical record-based measures but would have required about 50% fewer chart reviews. Agreement between medical record and automated data was generally high. Yet even in an integrated health care system with sophisticated information technology, automated data tended to underestimate the success rate in technical process measures for diabetes care and yielded different quartile performance rankings for facilities. Applying hybrid methodology yielded results consistent with the medical record but required less data to come from medical record reviews.

Implementation of a quality improvement initiative in Belgian diabetic foot clinics: feasibility and initial results.

PubMed

Doggen, Kris; Van Acker, Kristien; Beele, Hilde; Dumont, Isabelle; Félix, Patricia; Lauwers, Patrick; Lavens, Astrid; Matricali, Giovanni A; Randon, Caren; Weber, Eric; Van Casteren, Viviane; Nobels, Frank

2014-07-01

This article aims to describe the implementation and initial results of an audit-feedback quality improvement initiative in Belgian diabetic foot clinics. Using self-developed software and questionnaires, diabetic foot clinics collected data in 2005, 2008 and 2011, covering characteristics, history and ulcer severity, management and outcome of the first 52 patients presenting with a Wagner grade ≥ 2 diabetic foot ulcer or acute neuropathic osteoarthropathy that year. Quality improvement was encouraged by meetings and by anonymous benchmarking of diabetic foot clinics. The first audit-feedback cycle was a pilot study. Subsequent audits, with a modified methodology, had increasing rates of participation and data completeness. Over 85% of diabetic foot clinics participated and 3372 unique patients were sampled between 2005 and 2011 (3312 with a diabetic foot ulcer and 111 with acute neuropathic osteoarthropathy). Median age was 70 years, median diabetes duration was 14 years and 64% were men. Of all diabetic foot ulcers, 51% were plantar and 29% were both ischaemic and deeply infected. Ulcer healing rate at 6 months significantly increased from 49% to 54% between 2008 and 2011. Management of diabetic foot ulcers varied between diabetic foot clinics: 88% of plantar mid-foot ulcers were off-loaded (P10-P90: 64-100%), and 42% of ischaemic limbs were revascularized (P10-P90: 22-69%) in 2011. A unique, nationwide quality improvement initiative was established among diabetic foot clinics, covering ulcer healing, lower limb amputation and many other aspects of diabetic foot care. Data completeness increased, thanks in part to questionnaire revision. Benchmarking remains challenging, given the many possible indicators and limited sample size. The optimized questionnaire allows future quality of care monitoring in diabetic foot clinics. Copyright © 2014 John Wiley & Sons, Ltd.

Disease management programs in type 2 diabetes: quality of care.

PubMed

Berthold, Heiner K; Bestehorn, Kurt P; Jannowitz, Christina; Krone, Wilhelm; Gouni-Berthold, Ioanna

2011-06-01

To determine whether disease management programs (DMPs) for type 2 diabetes mellitus (T2DM) can improve some processes of care and intermediate outcomes. Two cross-sectional registries of patients with T2DM were used for data extraction before (previous cohort) and after (recent cohort) introduction of DMPs in Germany (N = 78,110). In the recent cohort, 15,293 patients were treated within the DMPs and 9791 were not. Processes of care, medications, and intermediate outcomes (achievement of treatment targets for low-density lipoprotein [LDL] cholesterol, blood pressure, and glycosylated hemoglobin [A1C]) were analyzed using multi- variable, multilevel logistic regression, adjusting for patient case-mix and physician-level clustering to derive odds ratios and 95% confidence intervals (CIs). Availability of structured diabetes education and of lipid, blood pressure, and A1C measurements increased over time. In DMP patients, availability was significantly higher for blood pressure and A1C but not for lipid measurements. Prescription of angiotensin-converting enzyme inhibitors, oral antidiabetic drugs, and insulin increased over time and was more common in DMP patients. Statin prescription increased over time but was not influenced by DMP status. Intermediate outcomes improved over time, but DMPs had no influence on intermediate outcomes except for reaching LDL cholesterol targets (odds ratio 1.12 [95% CI 1.06, 1.19] in favor of DMPs). While there may be some unmeasured confounding, our data suggest that improvement in processes of care by DMPs, as implemented in Germany, only partially translates into improvement of intermediate outcomes.

Improvement of the quality of diabetes control and decrease in the concentrations of AGE-products in patients with type 1 and insulin-treated type 2 diabetes mellitus: results from a 10 year-prospective, population-based survey on the quality of diabetes care in Germany (JEVIN).

PubMed

Schiel, Ralf; Franke, S; Appel, T; Voigt, U; Ross, I S; Kientsch-Engel, R; Müller, U A; Stein, G

2004-08-31

Advanced glycation end (AGE)-products are a complex group of compounds that have been implicated in diabetes related long-term complications. Up to the present only few data exist about serum levels of the AGE-proteins N-epsilon-Carboxymethyllysine (CML) and pentosidine in patients with diabetes mellitus. In the present 10-year, population-based trial of a selection-free cohort of patients with insulin-treated diabetes mellitus, serum CML and pentosidine levels were examined in correlation to the patients' quality of diabetes control and the prevalence of diabetes related long-term complications. Following the reunification of Germany in 1989 the health care system was decentralised. Up to 1994/95 the relative HbA1c (HbA1c/mean normal) of patients with type 1 diabetes increased (1.65 +/- 0.35 versus 1.52 +/- 0.31, p = 0.002). For patients with type 2 diabetes it remained constant (1.75 +/- 0.4 versus 1.78 +/- 0.31, p = 0.669). During the following period (from 1994/95 to 1999/2000) specialised diabetes care, structured treatment and teaching programmes (TTP), intensified insulin therapy and blood glucose self-monitoring for all patients were broadly implemented. This was accompanied by a substantial improvement in the relative HbA1c of both, patients with type 1 (1.48 +/- 0.3, p<0.0001), and insulin-treated type 2 diabetes mellitus (1.47 +/- 0.25, p<0.0001). During the same period the mean concentration of the AGE-product CML in the sera of patients with type 1 and insulin-treated type 2 diabetes decreased (type 1: 1994/95: 1158.1 +/- 410.0 ng/ml versus 1999/2000: 938.5 +/- 422.4 ng/ml, p<0.0001, type 2: 1994/94: 1244.7 +/- 1231.3 ng/ml versus 1999/2000: 970.9 +/- 458.6 ng/ml, p = 0.007). For pentosidine the same tendency was found for patients with type 1 diabetes (1994/95: 253.6 +/- 280.7 pmol/ml versus 1999/2000: 148.2 +/- 91.4 pmol/ml, p<0.0001). For patients with type 1 diabetes there was a positive correlation between the relative HbA1c-value calculated over

Improving diabetes care at primary care level with a multistrategic approach: results of the DIAPREM programme.

PubMed

Prestes, Mariana; Gayarre, Maria A; Elgart, Jorge F; Gonzalez, Lorena; Rucci, Enzo; Paganini, Jose M; Gagliardino, Juan J

2017-09-01

To present results, 1 year postimplementation at primary care level, of an integrated diabetes care programme including systemic changes, education, registry (clinical, metabolic, and therapeutic indicators), and disease management (DIAPREM). We randomly selected and trained 15 physicians and 15 nurses from primary care units of La Matanza County (intervention-IG) and another 15 physicians/nurses to participate as controls (control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for 1 year; both groups used structured medical records. Patients in IG had quarterly clinical appointments, whereas those in CG received traditional care. Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions. After 12 months, the dropout rate was significantly lower in IG than in CG. Whereas in IG HbA1c, blood pressure and lipid profile levels significantly decreased, no changes were recorded in CG. Drug prescriptions showed no significant changes in IG except a decrease in oral monotherapy. DIAPREM is an expedient and simple multistrategic model to implement at the primary care level in order to decrease patient dropout and improve control and treatment adherence, and quality of care of people with diabetes.

Enhancing Diabetes Self-care Among Rural African Americans With Diabetes

PubMed Central

Williams, Ishan C.; Utz, Sharon W.; Hinton, Ivora; Yan, Guofen; Jones, Randy; Reid, Kathryn

2015-01-01

Purpose The purpose of this study is to test the feasibility of conducting a community-based randomized controlled trial evaluating a culturally tailored community-based group diabetes self-management education (DSME) program among rural African Americans. Methods Thirty-two African American rural adults with type 2 diabetes were recruited and 25 adults were retained and participated in an interventional study designed to test the effectiveness of the “Taking Care of Sugar” DSME program for the 2-year follow-up. Participants were selected from rural central Virginia. Primary outcomes variables included average blood sugar levels, cardiovascular risk factors, and general physical and mental health. These outcomes were assessed at baseline, 3 months, 6 months, and 12 months post baseline. Results From baseline to 3-month follow-up assessment, participants exhibited significant improvement on several physiological and behavioral measures. Given the small sample size, hypothesis testing was limited. Results show change from baseline over time, illustrating that the primary outcome of A1C decreased, although not significant. Additionally, participants reported more knowledge about diabetes self-management and personal care skills (ie, exercise and foot care) that persisted over time. The feasibility of the culturally tailored DSME was established, and participation with the program was high. Conclusions A community-based group DSME program using storytelling is feasible. This research will help to inform clinicians and health policymakers as to the types of interventions that are feasible in a larger rural population. If such a program is carried out, we can improve knowledge, reduce complications, and improve quality of life among rural African Americans. PMID:24478047

Quality of chronic kidney disease management in primary care: a retrospective study.

PubMed

Van Gelder, Vincent A; Scherpbier-De Haan, Nynke D; De Grauw, Wim J C; Vervoort, Gerald M M; Van Weel, Chris; Biermans, Marion C J; Braspenning, Jozé C C; Wetzels, Jack F M

2016-01-01

Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model. Quality of care for chronic kidney disease patients in primary care can be improved. In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic

Exploring Canadian Physicians' Experiences With Type 2 Diabetes Care for Adult Indigenous Patients.

PubMed

Crowshoe, Lynden Lindsay; Henderson, Rita I; Green, Michael E; Jacklin, Kristen M; Walker, Leah M; Calam, Betty

2018-06-01

The perspectives of physicians caring for Indigenous patients with diabetes offer important insights into the provision of health-care services. The purpose of this study was to describe Canadian physicians' perspectives on diabetes care of Indigenous patients, a preliminary step in developing a continuing medical education intervention described elsewhere. Through in-depth semistructured interviews, Canadian family physicians and specialists with sizeable proportions of Indigenous clientele shared their experiences of working with Indigenous patients who have type 2 diabetes. Recruitment involved a purposive and convenience sampling strategy, identifying participants through existing research and the professional relationships of team members in the provinces of British Columbia, Alberta and Ontario. Participants addressed their understanding of factors contributing to the disease, approaches to care and recommendations for medical education. The research team framed a thematic analysis through a collaborative, decolonizing lens. The participants (n=28) included 3 Indigenous physicians, 21 non-Indigenous physicians and 4 non-Indigenous diabetes specialists. They practised in urban, reserve and rural adjacent-to-reserve contexts in 5 Canadian provinces. The physicians constructed a socially framed understanding of the complex contexts influencing Indigenous patients with diabetes in tension with structural barriers to providing diabetes care. As a result, physicians adapted care focusing on social factors and conditions that take into account the multigenerational impacts of colonization and the current social contexts of Indigenous peoples in Canada. Adaptations in diabetes care by physicians grounded in the historical, social and cultural contexts of their Indigenous patients offer opportunities for improving care quality, but policy and health system supports and structural competency are needed. Copyright © 2017 The Authors. Published by Elsevier Inc. All

The Contribution of Teleconsultation and Videoconferencing to Diabetes Care: A Systematic Literature Review

PubMed Central

van Gemert-Pijnen, Lisette; Dijkstra, Karin; Nijland, Nicol; Seydel, Erwin; Steehouder, Michaël

2007-01-01

Background A systematic literature review was carried out to study the benefits of teleconsultation and videoconferencing on the multifaceted process of diabetes care. Previous reviews focused primarily on usability of technology and considered mainly one-sided interventions. Objective The objective was to determine the benefits and deficiencies of teleconsultation and videoconferencing regarding clinical, behavioral, and care coordination outcomes of diabetes care. Methods Electronic databases (Medline, PiCarta, PsycINFO, ScienceDirect, Telemedicine Information Exchange, ISI Web of Science, Google Scholar) were searched for relevant publications. The contribution to diabetes care was examined for clinical outcomes (eg, HbA1c, blood pressure, quality of life), behavioral outcomes (patient-caregiver interaction, self-care), and care coordination outcomes (usability of technology, cost-effectiveness, transparency of guidelines, equity of care access). Randomized controlled trials (RCTs) with HbA1c as an outcome were pooled using standard meta-analytical methods. Results Of 852 publications identified, 39 met the inclusion criteria for electronic communication between (groups of) caregivers and patients with type 1, type 2, or gestational diabetes. Studies that evaluated teleconsultation or videoconferencing not particularly aimed at diabetes were excluded, as were those that described interventions aimed solely at clinical improvements (eg, HbA1c). There were 22 interventions related to teleconsultation, 13 to videoconferencing, and 4 to combined teleconsultation and videoconferencing. The heterogeneous nature of the identified videoconferencing studies did not permit a formal meta-analysis. Pooled results from the six RCTs of the identified teleconsultation studies did not show a significant reduction in HbA1c (0.03%, 95% CI = - 0.31% to 0.24%) compared to usual care. There was no significant statistical heterogeneity among the pooled RCTs (χ 2 7= 7.99, P = .33

Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes.

PubMed

Elissen, Arianne M J; Steuten, Lotte M G; Lemmens, Lidwien C; Drewes, Hanneke W; Lemmens, Karin M M; Meeuwissen, Jolanda A C; Baan, Caroline A; Vrijhoef, Hubertus J M

2013-10-01

The study aims to support decision making on how best to redesign diabetes care by investigating three potential sources of heterogeneity in effectiveness across trials of diabetes care management. Medline, CINAHL and PsycInfo were searched for systematic reviews and empirical studies focusing on: (1) diabetes mellitus; (2) adult patients; and (3) interventions consisting of at least two components of the chronic care model (CCM). Systematic reviews were analysed descriptively; empirical studies were meta-analysed. Pooled effect measures were estimated using a meta-regression model that incorporated study quality, length of follow-up and number of intervention components as potential predictors of heterogeneity in effects. Overall, reviews (n = 15) of diabetes care programmes report modest improvements in glycaemic control. Empirical studies (n = 61) show wide-ranging results on HbA1c, systolic blood pressure and guideline adherence. Differences between studies in methodological quality cannot explain this heterogeneity in effects. Variety in length of follow-up can explain (part of) the variability, yet not across all outcomes. Diversity in the number of included intervention components can explain 8-12% of the heterogeneity in effects on HbA1c and systolic blood pressure. The outcomes of chronic care management for diabetes are generally positive, yet differ considerably across trials. The most promising results are attained in studies with limited follow-up (<1 year) and by programmes including more than two CCM components. These factors can, however, explain only part of the heterogeneity in effectiveness between studies. Other potential sources of heterogeneity should be investigated to ensure implementation of evidence-based improvements in diabetes care. © 2012 John Wiley & Sons Ltd.

Relationship Between Quality of Comorbid Condition Care and Costs for Cancer Survivors

PubMed Central

Snyder, Claire F.; Herbert, Robert J.; Blackford, Amanda L.; Neville, Bridget A.; Wolff, Antonio C.; Carducci, Michael A.; Earle, Craig C.

2016-01-01

Purpose: To estimate the association between cancer survivors’ comorbid condition care quality and costs; to determine whether the association differs between cancer survivors and other patients. Methods: Using the SEER–Medicare-linked database, we identified survivors of breast, prostate, and colorectal cancers who were diagnosed in 2004, enrolled in Medicare fee-for-service for at least 12 months before diagnosis, and survived ≥ 3 years. Quality of care was assessed using nine process indicators for chronic conditions, and a composite indicator representing seven avoidable outcomes. Total costs on the basis of Medicare amount paid were grouped as inpatient and outpatient. We examined the association between care quality and costs for cancer survivors, and compared this association among 2:1 frequency-matched noncancer controls, using comparisons of means and generalized linear regressions. Results: Our sample included 8,661 cancer survivors and 17,332 matched noncancer controls. Receipt of recommended care was associated with higher outpatient costs for eight indicators, and higher inpatient and total costs for five indicators. For three measures (visit every 6 months for patients with chronic obstructive pulmonary disease or diabetes, and glycosylated hemoglobin or fructosamine every 6 months for patients with diabetes), costs for cancer survivors who received recommended care increased less than for noncancer controls. The absence of avoidable events was associated with lower costs of each type. An annual eye examination for patients with diabetes was associated with lower inpatient costs. Conclusion: Higher-quality processes of care may not reduce short-term costs, but the prevention of avoidable outcomes reduces costs. The association between quality and cost was similar for cancer survivors and noncancer controls. PMID:27165487

Illness perception, diabetes knowledge and self-care practices among type-2 diabetes patients: a cross-sectional study.

PubMed

Kugbey, Nuworza; Oppong Asante, Kwaku; Adulai, Korkor

2017-08-10

Self-care practices among persons living with type-2 diabetes are very crucial in diabetes manages as poor self-care results in complications. However, little research exists within the Ghanaian context. This study examined whether type-2 diabetes patients' illness perception and diabetes knowledge significantly predict diabetes self-care practices. A cross-sectional survey design was employed and a total of 160 participants (45 males and 115 females) were sampled from a general hospital in Accra. A self-administered questionnaire measuring illness perception, diabetes knowledge and diabetes self-care practices as well as demographic checklist were used collect data. Results showed that illness perception and diabetes knowledge significantly predicted overall diabetes self-care practices. Analysis of domain specific self-care practices showed that patients' diet was significantly predicted by illness perception and diabetes knowledge. Exercise was significantly predicted by only illness perception while blood sugar testing and diabetes foot-care were significantly predicted by diabetes knowledge. Cognitive and emotional representation of diabetes and diabetes knowledge are key determinants of patients' diabetes self-care practices. It is therefore important that appropriate psychosocial interventions are developed to help patients' adherence to recommended self-care practices.

Diabetes Care in Brazil.

PubMed

Coutinho, Walmir F; Silva Júnior, Wellington Santana

2015-01-01

The diabetes epidemic affects most countries across the world and is increasing at alarming rates in Latin America. Nearly 12 million individuals have diabetes in Brazil, and the current prevalence ranges from 6.3% to 13.5%, depending on the region and the diagnostic criteria adopted in each study. To provide an overview of diabetes care in Brazil, focusing on studies of diabetes epidemiology, prevalence of patients within the standard targets of care, and economic burden of diabetes and its complications. SciELO and PubMed searches were performed for the terms "diabetes," "Brazil," "Brazilian," and "health system"; relevant literature from 1990 to 2015 was selected. Additional articles identified from reference list searches were also included. All articles selected were published in Portuguese and/or English. Recent studies detected a prevalence of gestational diabetes mellitus of nearly 20%. Among patients with type 1 diabetes, almost 90% fail to reach target of glycemic control, with less than 30% receiving treatment for both hypertension and dyslipidemia. More than 75% of patients with type 2 diabetes are either overweight or obese. Most of these patients fail to reach glycemic targets (42.1%) and less than 30% reached the target for systolic and diastolic blood pressure, body mass index, or low-density lipoprotein cholesterol. Only 0.2% of patients reach all these anthropometric and metabolic targets. Brazil is the fourth country in the world in number of patients with diabetes. Regardless of the diabetes type, the majority of patients do not meet other metabolic control goals. The economic burden of diabetes and its complications in Brazil is extremely high, and more effective approaches for preventions and management are urgently needed. Copyright © 2015. Published by Elsevier Inc.

Diabetic Foot Disease, Self-Care and Clinical Monitoring in Adults with Type 2 Diabetes: The Alberta's Caring for Diabetes (ABCD) Cohort Study.

PubMed

Al Sayah, Fatima; Soprovich, Allison; Qiu, Weiyu; Edwards, Alun L; Johnson, Jeffrey A

2015-10-01

To examine the prevalence and predictors of foot disease, self-care and clinical monitoring in adults with type 2 diabetes in Alberta, Canada. Baseline data from a prospective cohort of adults with type 2 diabetes were used. Assessment of foot disease included self-reported peripheral neuropathy, peripheral vasculopathy, foot or leg ulcer/infection or gangrene/amputation. Foot self-care was assessed using the Summary of Diabetes Self-Care Activities, and clinical monitoring using patients' reports of having feet checked for lesions or sensory loss. The mean age of respondents (N=2040) was 64 (SD 10.7) years; 45% were female, and 91% were Caucasian. Peripheral neuropathy was reported by 18% of the respondents, peripheral vasculopathy by 28%, ulcer/infection by 6% and gangrene/amputation by 1.4%. Only 14% of respondents performed foot self-care behaviours ≥6 days per week, and only 41% and 34% had their feet clinically checked for lesions or sensory loss, respectively. Predictors of foot disease included longer duration of diabetes, smoking, depressive symptoms, low self-efficacy and a history of cardiovascular diseases. Predictors of good self-care included older age, female sex, longer duration of diabetes and no report of hyperlipidemia. Predictors of clinical monitoring included female sex, current smoking, residing in urban areas, longer duration of diabetes, and histories of heart disease or hyperlipidemia. Peripheral neuropathy and vasculopathy were the most common reported foot problems in this population. Foot self-care is generally infrequent, and clinical monitoring is performed for less than half of these patients, with significant variations by patient demographics and clinical presentation. Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

Diabetes quality improvement in Department of Veterans Affairs Ambulatory Care Clinics: a group-randomized clinical trial.

PubMed

Reiber, Gayle E; Au, David; McDonell, Mary; Fihn, Stephan D

2004-05-01

To conduct a group-randomized clinical trial to determine whether regular feedback to primary care providers of synthesized information on patients' health, function, and satisfaction would demonstrate improved outcomes for their patients with diabetes. Patients in General Internal Medicine Clinics Department of Veterans Affairs (VA) Medical Centers were randomized into seven intervention or control firms. Patient self-reported information was collected by mail on general health, diabetes, and up to five other chronic conditions. Patients with diabetes received the Seattle Diabetes Questionnaire, the 36-item Medical Outcomes Study short form (SF-36), and a validated patient satisfaction questionnaire at regular intervals. Data from self-report, clinical, pharmacy, and laboratory sources were synthesized into patient-specific feedback reports that intervention providers received before patients' visits. The timely delivery to primary care providers of state-of-the-art patient-feedback reports that identified patient issues and areas for improvement did not result in significant improvements in patient outcomes between the intervention and control firms. Outcomes in diabetic patients whose providers received synthesized patient data before visits were no better than in those receiving care from control firms. Future studies may benefit from substantial involvement in patients discussing, problem solving, and goal setting in addition to use of timely synthesized patient data.

Mental health issues decrease diabetes-specific quality of life independent of glycaemic control and complications: findings from Australia’s living with diabetes cohort study

PubMed Central

2013-01-01

Background While factors associated with health-related quality of life for people with chronic diseases including diabetes are well researched, far fewer studies have investigated measures of disease-specific quality of life. The purpose of this study is to assess the impact of complications and comorbidities on diabetes-specific quality of life in a large population-based cohort of type 2 diabetic patients. Methods The Living with Diabetes Study recruited participants from the National Diabetes Services Scheme in Australia. Data were collected via a mailed self-report questionnaire. Diabetes-specific quality of life was measured using the Audit of Diabetes-Dependent Quality of Life (ADDQoL) questionnaire. The analyses are for 3609 patients with type 2 diabetes. Regression models with adjustment for control variables investigated the association of complications and comorbidities with diabetes-specific quality of life. Next, the most parsimonious model for diabetes-specific quality of life after controlling for important covariates was examined. Results The expected associations with better diabetes-specific quality of life were evident, such as increased income, not on insulin, better glycaemic control and older age. However, being single and having been diagnosed with cancer were also associated with better ADDQoL. Additionally, poorer diabetes-specific quality of life was strongly sensitive to the presence of diabetes complications and mental health conditions such as depression, anxiety and schizophrenia. These relationships persisted after adjustment for gender, age, duration of diabetes, treatment regimen, sampling region and other treatment and socio-demographic variables. Conclusions A greater appreciation of the complexities of diabetes-specific quality of life can help tailor disease management and self-care messages given to patients. Attention to mental health issues may be as important as focusing on glycaemic control and complications. Therefore

Results from 15years of quality surveillance for a National Indigenous Point-of-Care Testing Program for diabetes.

PubMed

Shephard, Mark; Shephard, Anne; McAteer, Bridgit; Regnier, Tamika; Barancek, Kristina

2017-12-01

Diabetes is a major health problem for Australia's Aboriginal and Torres Strait Islander peoples. Point-of-care testing for haemoglobin A1c (HbA1c) has been the cornerstone of a long-standing program (QAAMS) to manage glycaemic control in Indigenous people with diabetes and recently, to diagnose diabetes. The QAAMS quality management framework includes monthly testing of quality control (QC) and external quality assurance (EQA) samples. Key performance indicators of quality include imprecision (coefficient of variation [CV%]) and percentage acceptable results. This paper reports on the past 15years of quality testing in QAAMS and examines the performance of HbA1c POC testing at the 6.5% cut-off recommended for diagnosis. The total number of HbA1c EQA results submitted from 2002 to 2016 was 29,093. The median imprecision for EQA testing by QAAMS device operators averaged 2.81% (SD 0.50; range 2.2 to 3.9%) from 2002 to 2016 and 2.44% (SD 0.22; range 2.2 to 2.9%) from 2009 to 2016. No significant difference was observed between the median imprecision achieved in QAAMS and by Australasian laboratories from 2002 to 2016 (p=0.05; two-tailed paired t-test) and from 2009 to 2016 (p=0.17; two-tailed paired t-test). For QC testing from 2009 to 2016, imprecision averaged 2.5% and 3.0% for the two levels of QC tested. Percentage acceptable results averaged 90% for QA testing from 2002 to 2016 and 96% for QC testing from 2009 to 2016. The DCA Vantage was able to measure a patient and an EQA sample with an HbA1c value close to 6.5% both accurately and precisely. HbA1c POC testing in QAAMS has remained analytically sound, matched the quality achieved by Australasian laboratories and met profession-derived analytical goals for 15years. Copyright © 2017 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.

The utah beacon experience: integrating quality improvement, health information technology, and practice facilitation to improve diabetes outcomes in small health care facilities.

PubMed

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J; North, Christie

2014-01-01

The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010-2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC(3) was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients' diabetes outcomes at 21 participating smaller, independent clinics. Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC(3) helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients' diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC(3) Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC(3) Beacon practices are currently smoothly transitioning to new models of care such as Patient

Content, participants and outcomes of three diabetes care programmes in three low and middle income countries.

PubMed

Van Olmen, Josefien; Marie, Ku Grace; Christian, Darras; Clovis, Kalobu Jean; Emery, Bewa; Maurits, Van Pelt; Heang, Hen; Kristien, Van Acker; Natalie, Eggermont; François, Schellevis; Guy, Kegels

2015-06-01

To improve access and quality of diabetes care for people in low-income countries, it is important to understand which elements of diabetes care are effective. This paper analyses three diabetes care programmes in the DR Congo, Cambodia and the Philippines. Three programmes offering diabetes care and self-management were selected. Programme information was collected through document review and interviews. Data about participants' characteristics, health outcomes, care utilisation, expenditures, care perception and self-management were extracted from a study database. Comparative univariate analyses were performed. Kin-réseau (DR Congo) is an urban primary care network with 8000 patients. MoPoTsyo (Cambodia) is a community-based peer educator network, covering 7000 patients. FiLDCare (Philippines) is a programme in which 1000 patients receive care in a health facility and self-management support from a community health worker. Content of care of the programmes is comparable, the focus on self-management largest in MoPoTsyo. On average, Kin-réseau patients have a higher age, longer diabetes history and more overweight. MoPoTsyo includes most female, most illiterate and most lean patients. Health outcomes (HbA1C level, systolic blood pressure, diabetes foot lesions) were most favourable for MoPoTsyo patients. Diabetes-related health care expenditure was highest for FiLDCare patients. This study shows it possible to maintain a diabetes programme with minimal external resources, offering care and self-management support. It also illustrates that health outcomes of persons with diabetes are determined by their bio-psycho-social characteristics and behaviour, which are each subject to the content of care and the approach to chronic illness and self-management of the programme, in turn influenced by the larger context. Copyright © 2014 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Cardiovascular Disease and Risk Management: Review of the American Diabetes Association Standards of Medical Care in Diabetes 2018.

PubMed

Chamberlain, James J; Johnson, Eric L; Leal, Sandra; Rhinehart, Andrew S; Shubrook, Jay H; Peterson, Lacie

2018-05-01

The American Diabetes Association (ADA) annually updates its Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. For the 2018 standards, the ADA Professional Practice Committee searched MEDLINE through November 2017 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C depending on the quality of evidence or E for expert consensus or clinical experience. The standards were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. This synopsis focuses on guidance relating to cardiovascular disease and risk management in nonpregnant adults with diabetes. Recommendations address diagnosis and treatment of cardiovascular risk factors (hypertension and dyslipidemia), aspirin use, screening for and treatment of coronary heart disease, and lifestyle interventions.

Meeting the Health Care Needs of a Rural Hispanic Migrant Population With Diabetes

ERIC Educational Resources Information Center

Heuer, Loretta; Hess, Carla W.; Klug, Marilyn G.

2004-01-01

There is a need for models of health care that provide accessible, culturally appropriate, quality services to the population of Hispanic migrant farmworkers at risk for or diagnosed with diabetes. The purposes of this study were to describe the Migrant Health Service, Inc (MHSI), Diabetes Program, the conceptual model on which it is based, and 4…

A combination of process of care and clinical target among type 2 diabetes mellitus patients in general medical clinics and specialist diabetes clinics at hospital levels.

PubMed

Sieng, Sokha; Hurst, Cameron

2017-08-07

This study compares a combination of processes of care and clinical targets among patients with type 2 diabetes mellitus (T2DM) between specialist diabetes clinics (SDCs) and general medical clinics (GMCs), and how differences between these two types of clinics differ with hospital type (community, provincial and regional). Type 2 diabetes mellitus patient medical records were collected from 595 hospitals (499 community, 70 provincial, 26 regional) in Thailand between April 1 to June 30, 2012 resulting in a cross-sectional sample of 26,860 patients. Generalized linear mixed modeling was conducted to examine associations between clinic type and quality of care. The outcome variables of interest were split into clinical targets and process of care. A subsequent subgroup analysis was conducted to examine if the nature of clinical target and process of care differences between GMCs and SDCs varied with hospital type (regional, provincial, community). Regardless of the types of hospitals (regional, provincial, or community) patients attending SDCs were considerably more likely to have eye and foot exam. In terms of larger hospitals (regional and provincial) patients attending SDCs were more likely to achieve HbA1c exam, All FACE exam, BP target, and the Num7Q. Interestingly, SDCs performed better than GMCs at only provincial hospitals for LDL-C target and the All7Q. Finally, patients with T2DM who attended community hospital-GMCs had a better chance of achieving the blood pressure target than patients who attended community hospital-SDCs. Specialized diabetes clinics outperform general medical clinics for both regional and provincial hospitals for all quality of care indicators and the number of quality of care indicators achieved was never lower. However, this better performance of SDC was not observed in community hospital. Indeed, GMCs outperformed SDCs for some quality of care indicators in the community level setting.

Addressing Literacy and Numeracy to Improve Diabetes Care

PubMed Central

Cavanaugh, Kerri; Wallston, Kenneth A.; Gebretsadik, Tebeb; Shintani, Ayumi; Huizinga, Mary Margaret; Davis, Dianne; Gregory, Rebecca Pratt; Malone, Robb; Pignone, Michael; DeWalt, Darren; Elasy, Tom A.; Rothman, Russell L.

2009-01-01

OBJECTIVE Diabetic patients with lower literacy or numeracy skills are at greater risk for poor diabetes outcomes. This study evaluated the impact of providing literacy- and numeracy-sensitive diabetes care within an enhanced diabetes care program on A1C and other diabetes outcomes. RESEARCH DESIGN AND METHODS In two randomized controlled trials, we enrolled 198 adult diabetic patients with most recent A1C ≥7.0%, referred for participation in an enhanced diabetes care program. For 3 months, control patients received care from existing enhanced diabetes care programs, whereas intervention patients received enhanced programs that also addressed literacy and numeracy at each institution. Intervention providers received health communication training and used the interactive Diabetes Literacy and Numeracy Education Toolkit with patients. A1C was measured at 3 and 6 months follow-up. Secondary outcomes included self-efficacy, self-management behaviors, and treatment satisfaction. RESULTS At 3 months, both intervention and control patients had significant improvements in A1C from baseline (intervention −1.50 [95% CI −1.80 to −1.02]; control −0.80 [−1.10 to −0.30]). In adjusted analysis, there was greater improvement in A1C in the intervention group than in the control group (P = 0.03). At 6 months, there were no differences in A1C between intervention and control groups. Self-efficacy improved from baseline for both groups. No significant differences were found for self-management behaviors or satisfaction. CONCLUSIONS A literacy- and numeracy-focused diabetes care program modestly improved self-efficacy and glycemic control compared with standard enhanced diabetes care, but the difference attenuated after conclusion of the intervention. PMID:19741187

Diabetes Health Disparities

PubMed Central

Peek, Monica E.; Cargill, Algernon; Huang, Elbert S.

2008-01-01

Racial and ethnic minorities bear a disproportionate burden of the diabetes epidemic; they have higher prevalence rates, worse diabetes control, and higher rates of complications. This article reviews the effectiveness of health care interventions at improving health outcomes and/or reducing diabetes health disparities among racial/ethnic minorities with diabetes. Forty-two studies met inclusion criteria. On average, these health care interventions improved the quality of care for racial/ethnic minorities, improved health outcomes (such as diabetes control and reduced diabetes complications), and possibly reduced health disparities in quality of care. There is evidence supporting the use of interventions that target patients (primarily through culturally tailored programs), providers (especially through one-on-one feedback and education), and health systems (particularly with nurse case managers and nurse clinicians). More research is needed in the areas of racial/ethnic minorities other than African Americans and Latinos, health disparity reductions, long-term diabetes-related outcomes, and the sustainability of health care interventions over time. PMID:17881626

Using quality experts from manufacturing to transform primary care.

PubMed

Steiner, Rose M; Walsworth, David T

2010-01-01

Improving Performance in Practice (IPIP) is an initiative convened by the American Board of Medical Specialties. It investigates the efficacy of coaches in helping primary-care practices improve the care of patients with diabetes and asthma. Most IPIP states use coaches who have a health care background, and are trained in quality and process improvement. Michigan uses quality experts from the manufacturing industry who are educated regarding the health care environment, which enables them to perform as quality-improvement coaches (QICs) in primary-care practices. In this case study, ninety-six quality experts were trained to coach primary-care practices, with 53 currently assigned to offices, and others assisting as needed. Practice teams and QICs identify gaps in care and office practices with the use of assorted quality-improvement tools. Reports are made monthly to describe clinical and process measures and methods used. Michigan has 33 practices engaged, involving 205 physicians and 40 midlevel providers. The teaming of quality experts from the manufacturing industry with primary-care office providers and staff resulted in office efficiency, improved care provided, and progress toward attainment of a patient-centered medical home (PCMH). Quality experts from manufacturing volunteered to coach for improvements in primary care. The efforts of QICs have been successful. Because the QICs are volunteers, sustainability of the Michigan Improving Performance in Practice program is a challenge.

Multistrategic approach to improve quality of care of people with diabetes at the primary care level: Study design and baseline data.

PubMed

Prestes, Mariana; Gayarre, María Angelica; Elgart, Jorge Federico; Gonzalez, Lorena; Rucci, Enzo; Gagliardino, Juan José

2017-04-01

To test the one year-post effect of an integrated diabetes care program that includes system changes, education, registry (clinical, metabolic and therapeutic indicators) and disease management (DIAPREM), implemented at primary care level, on care outcomes and costs. We randomly selected 15 physicians and 15 nurses from primary care units of La Matanza County to be trained (Intervention-IG) and another 15 physicians/nurses to use as controls (Control-CG). Each physician-nurse team controlled and followed up 10 patients with type 2 diabetes for one year; both groups use structured medical data registry. Patients in IG had quarterly clinical appointments whereas those in CG received traditional care. DIAPREM includes system changes (use of guidelines, programmed quarterly controls and yearly visits to the specialist) and education (physicians' and nurses' training courses). Statistical data analysis included parametric/nonparametric tests according to data distribution profile and Chi-squared test for proportions. Baseline data from both groups showed comparable values and 20-30% of them did not perform HbA1c and lipid profile measurements. Majority were obese, 59% had HbA1C ≥7%, 86% fasting blood glucose ≥100mg/dL, 45%, total cholesterol ≥200mg/dL, and 92% abnormal HDL- and LDL-cholesterol values. Similarly, micro and macroangiopathic complications had not been detected in the previous year. Most patients received oral antidiabetic agents (monotherapy), and one third was on insulin (mostly a single dose of an intermediate/long-acting formulation). Most people with hypertension received specific drug treatment but only half of them reached target values; dyslipidemia treatment showed similar data. Baseline data demonstrated the need of implementing an intervention to improve diabetes care and treatment outcomes. Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

The association between quality of care and the intensity of diabetes disease management programs.

PubMed

Mangione, Carol M; Gerzoff, Robert B; Williamson, David F; Steers, W Neil; Kerr, Eve A; Brown, Arleen F; Waitzfelder, Beth E; Marrero, David G; Dudley, R Adams; Kim, Catherine; Herman, William; Thompson, Theodore J; Safford, Monika M; Selby, Joe V

2006-07-18

Although disease management programs are widely implemented, little is known about their effectiveness. To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels. Cross-sectional study. Patients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%). 8661 adults with diabetes who completed a survey (2000-2001) and had medical record data. Physician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use. Increased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management. Physician groups were not randomly sampled from population-based listings, and disease

Improving quality of care in people with Type 2 diabetes through the Associazione Medici Diabetologi-annals initiative: a long-term cost-effectiveness analysis.

PubMed

Giorda, C B; Nicolucci, A; Pellegrini, F; Kristiansen, C K; Hunt, B; Valentine, W J; Vespasiani, G

2014-05-01

The Associazione Medici Diabetologi-annals initiative is a physician-led quality-of-care improvement scheme that has been shown to improve HbA1c concentration, blood pressure, lipid profiles and BMI in enrolled people with Type 2 diabetes. The present analysis investigated the long-term cost-effectiveness of enrolling people with Type 2 diabetes in the Associazione Medici Diabetologi-annals initiative compared with conventional management. Long-term projections of clinical outcomes and direct costs (in 2010 Euros) were made using a published and validated model of Type 2 diabetes in people with Type 2 diabetes who were either enrolled in the Associazione Medici Diabetologi-annals initiative or who were receiving conventional management. Treatment effects were based on mean changes from baseline seen at 5 years after enrolment in the scheme. Costs and clinical outcomes were discounted at 3% per annum. The Associazione Medici Diabetologi-annals initiative was associated with improvements in mean discounted life expectancy and quality-adjusted life expectancy of 0.55 years (95% CI 0.54-0.57) years and 0.48 quality-adjusted life years (95% CI 0.46-0.49), respectively, compared with conventional management. Whilst treatment costs were higher in the Associazione Medici Diabetologi-annals arm, this was offset by savings as a result of the reduced incidence and treatment of diabetes-related complications. The Associazione Medici Diabetologi-annals initiative was found to be cost-saving over patient lifetimes compared with conventional management [€ 37,289 (95% CI 37,205-37,372) vs € 41,075 (95% CI 40,956-41,155)]. Long-term projections indicate that the physician-led Associazione Medici Diabetologi-annals initiative represents a cost-saving method of improving long-term clinical outcomes compared with conventional management of people with Type 2 diabetes in Italy. © 2013 The Authors. Diabetic Medicine © 2013 Diabetes UK.

Multicentre randomized controlled trial of structured transition on diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes (Transition Trial).

PubMed

Spaic, Tamara; Mahon, Jeff L; Hramiak, Irene; Byers, Nicole; Evans, Keira; Robinson, Tracy; Lawson, Margaret L; Malcolm, Janine; Goldbloom, Ellen B; Clarson, Cheril L

2013-10-09

Transition from pediatric to adult diabetes care is a high risk period during which there is an increased rate of disengagement from care. Suboptimal transition has been associated with higher risks for acute and chronic diabetes-related complications. The period of emerging adulthood challenges current systems of healthcare delivery as many young adults with type 1 diabetes (T1D) default from diabetes care and are at risk for diabetes complications which are undetected and therefore untreated. Despite the importance of minimizing loss to follow-up there are no randomized control trials evaluating models of transition from pediatric to adult diabetes care. This is a multicentre randomized controlled trial. A minimum of 188 subjects with T1D aged between 17 and 20 years will be evaluated. Eligible subjects will be recruited from three pediatric care centres and randomly assigned in a 1:1 ratio to a structured transition program that will span 18 months or to receive standard diabetes care. The structured transition program is a multidisciplinary, complex intervention aiming to provide additional support in the transition period. A Transition Coordinator will provide transition support and will provide the link between pediatric and adult diabetes care. The Transition Coordinator is central to the intervention to facilitate ongoing contact with the medical system as well as education and clinical support where appropriate. Subjects will be seen in the pediatric care setting for 6 months and will then be transferred to the adult care setting where they will be seen for one year. There will then be a one-year follow-up period for outcome assessment. The primary outcome is the proportion of subjects who fail to attend at least one outpatient adult diabetes specialist visit during the second year after transition to adult diabetes care. Secondary outcome measures include A1C frequency measurement and levels, diabetes related emergency room visits and hospital

Primary care provider turnover and quality in managed care organizations.

PubMed

Plomondon, Mary E; Magid, David J; Steiner, John F; MaWhinney, Samantha; Gifford, Blair D; Shih, Sarah C; Grunwald, Gary K; Rumsfeld, John S

2007-08-01

To examine the association between primary care provider turnover in managed care organizations and measures of member satisfaction and preventive care. Retrospective cohort study of a national sample of 615 managed care organizations that reported HEDIS data to the National Committee for Quality Assurance from 1999 through 2001. Multivariable hierarchical regression modeling was used to evaluate the association between health plan primary care provider turnover rate and member satisfaction and preventive care measures, including childhood immunization, well-child visits, cholesterol, diabetes management, and breast and cervical cancer screening, adjusting for patient and organizational characteristics, time, and repeated measures. The median primary care provider turnover rate was 7.1% (range, 0%-53.3%). After adjustment for plan characteristics, health plans with higher primary care provider turnover rates had significantly lower measures of member satisfaction, including overall rating of healthcare (P < .01). A 10% higher primary care provider turnover rate was associated with 0.9% fewer members rating high overall satisfaction with healthcare. Health plans with higher provider turnover rates also had lower rates of preventive care, including childhood immunization (P = .045), well-child visits (P = .002), cholesterol screening after cardiac event (P = .042), and cervical cancer screening (P = .024). For example, a 10% higher primary care provider turnover was associated with a 2.7% lower rate of child-members receiving well-child visits in the first 15 months of life. Primary care provider turnover is associated with several measures of care quality, including aspects of member satisfaction and preventive care. Future studies should evaluate whether interventions to reduce primary care provider turnover can improve quality of care and patient outcomes.

[Quality in diabetes mellitus control in Primary Care Units in Mexico. A study of the perspectives of the patient's family].

PubMed

Avalos García, María Isabel; López Ramón, Concepción; Morales García, Manuel Higinio; Priego Álvarez, Heberto Romeo; Garrido Pérez, Silvia María Guadalupe; Cargill Foster, Nelly Ruth

2017-01-01

To identify the perspectives of the patient's family in the quality of diabetes mellitus control. Qualitative methodology of exploratory design, oriented towards health services research, conducted in 2014 using non-probability sampling. Primary Care Units mainly situated in the state of Tabasco, Mexico. 42 family members were selected, who agreed to participate voluntarily in the study. Six focus groups were set up; interview guides and group dynamics were employed. The information was documented, saturated and categorised; the most representative discourses were used, and conclusions reached. The results show a highly critical position of the families as regards the patient, some of which appear justified, and others have a cultural, historical, and to some extent, an ignorance connotation. They have also commented on the health care and the role that patients and families can play, in both cases, also expressed critically. The family perspectives reveal what they think and feel about diabetes mellitus. It is important to note their lack of support and the content of their expressions due to lack of knowledge of the disease. Their discourses are critical, mythical, and with false beliefs of the fear of being future carriers of the disease. They feel sorry for the patient but they resist taking care of them, and do not want a life with diabetes. The family is the closest support for patients and an invaluable human resource for health services. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

Nerve damage from diabetes - self-care

MedlinePlus

... this page: //medlineplus.gov/ency/patientinstructions/000326.htm Nerve damage from diabetes - self-care To use the ... or at other unusual times. Treating and Preventing Nerve Damage from Diabetes Treating diabetic neuropathy can make ...

Diabetes Patient Tracker, a personal digital assistant-based diabetes management system for primary care practices in Oklahoma.

PubMed

Nagykaldi, Zsolt; Mold, James W

2003-01-01

It has been demonstrated that electronic patient registries combined with a clinical decision support system have a significant positive impact on the documentation and delivery of services provided by health care professionals. While implementation of available commercial systems has not always been proven effective in a number of primary care practices, development and implementation of such a system in a practice-based research network might enhance successful implementation. Physicians in our practice-based research network (Oklahoma Physicians Resource/Research Network) initiated a project that aimed at designing, testing, and implementing a personal digital assistant-based diabetes management system. We utilized the "best practice" approach to determine the principles on which the application must operate. System development and beta testing were also accomplished based on the direct feedback of user clinicians. Practice Enhancement Assistants (PEAs) were available in the practices for assistance with implementation. Implementation of the Diabetes Patient Tracker (DPT) resulted in a significant improvement (p<0.05) in nine of 10 diabetic quality of care measures compared with pre-intervention levels in 20 primary care practices. Regular PEA visits similarly increased the number of foot exams and retinal exams performed in the last year (p=0.03 and 0.02, respectively). DPT is a low-cost, feasible, easily implementable, and very effective paper-less tool that significantly improves patient care and documentation in primary care practices.

The Guyana Diabetes and Foot Care Project: Improved Diabetic Foot Evaluation Reduces Amputation Rates by Two-Thirds in a Lower Middle Income Country

PubMed Central

Sibbald, R. Gary; Martin, Carlos

2015-01-01

Background. Type 2 diabetes is the fourth leading cause of death in Guyana, South America. A complex, interprofessional, quality improvement intervention to improve foot and diabetes care was rolled out in two phases. Methods & Findings. Phase 1: Establishment of an Interprofessional Diabetic Foot Center (DFC) of Excellence to improve foot care and reduce diabetes-related amputations at the national referral hospital. Phase 2: Regionalization to cover 90% of the Guyanese population and expansion to include improved management of diabetes and hypertension. Fourteen key opinion leaders were educated and 340 health care professionals from 97 facilities trained. Eight centers for the evaluation and treatment of foot ulcers were established and 7567 people with diabetes evaluated. 3452 participants had foot screening and 48% were deemed high risk; 10% of these had undocumented foot ulcers. There was a 68% reduction in rate of major amputations (P < 0.0001); below knee amputations were decreased by 80%, while above knee amputations were unchanged. An increased association of diabetes with women (F/M = 2.09) and increased risk of major amputation in men [odds ratio 2.16 (95% CI 1.83, 2.56)] were documented. Conclusions. This intervention improved foot care with reduction in major amputations sustained over 5 years. PMID:26089901

Patient-initiated Electronic Messages and Quality of Care for Patients With Diabetes and Hypertension in a Large Fee-for-Service Medical Group: Results From a Natural Experiment.

PubMed

McClellan, Sean R; Panattoni, Laura; Chan, Albert S; Tai-Seale, Ming

2016-03-01

Few studies have examined the association between patient-initiated electronic messaging (e-messaging) and clinical outcomes in fee-for-service settings. To estimate the association between patient-initiated e-messages and quality of care among patients with diabetes and hypertension. Longitudinal observational study from 2009 to 2013. In March 2011, the medical group eliminated a $60/year patient user fee for e-messaging and established a provider payment of $3-5 per patient-initiated e-message. Quality of care for patients initiating e-messages was compared before and after March 2011, relative to nonmessaging patients. Propensity score weighting accounted for differences between e-messaging and nonmessaging patients in generalized estimating equations. Large multispecialty practice in California compensating providers' fee-for-service. Patients with diabetes (N=4232) or hypertension (N=15,463) who had activated their online portal but not e-messaged before e-messaging became free. Quality of care included HEDIS-based process measures for hemoglobin (Hb) A1c, blood pressure, low-density lipoprotein (LDL), nephropathy, and retinopathy tests, and outcome measures for HbA1c, blood pressure, and LDL. E-messaging was measured as counts of patient-initiated e-message threads sent to providers. Patients were categorized into quartiles by e-messaging frequency. The probability of annually completing indicated tests increased by 1%-7% for e-messaging patients, depending on the outcome and e-messaging frequency. E-messaging was associated with small improvements in HbA1c and LDL for some patients with diabetes. Patient-initiated e-messaging may increase the likelihood of completing recommended tests, but may not be sufficient to improve clinical outcomes for most patients with diabetes or hypertension without additional interventions.

Improving diabetes care for people with intellectual disabilities: a qualitative study exploring the perceptions and experiences of professionals in diabetes and intellectual disability services.

PubMed

Brown, M; Taggart, L; Karatzias, T; Truesdale, M; Walley, R; Northway, R; Macrae, S; Carey, M; Davies, M

2017-05-01

Globally, diabetes is increasing with concerns about the impact on outcomes, including premature death and the costs associated with managing the condition. Research indicates that adults with intellectual disabilities (ID) are two to three times more likely to develop diabetes; however, there has been limited focus on diabetes service utilisation in this population. The aim of this study is to explore the perceptions and experiences of diabetes and ID practitioners. A series of 1:1 semi-structured interviews were undertaken in one Scottish health service area. In total, 29 qualitative interviews were conducted: 10 with diabetes practitioners from primary and secondary care, 14 from ID services and 5 from community care services regarding diabetes service provision for this population. Thematic content analysis was undertaken to identify the themes and subthemes. Three main themes were identified: (1) enabling access to services to meet diabetes-related care needs of people with ID; (2) communication and service improvements between staff, patients and across services; and (3) providing person-centred diabetes care and developing adapted resources to increase patient self-care. The findings of this study have important international implications in how diabetes practitioners plan and deliver services for people with ID and other vulnerable groups with limited cognitive ability and communication skills and difficulties in self-management. The findings highlight that access to diabetes education and adapted resources is needed, and if 'reasonable adjustments' are made to service provision and practice, people with ID can benefit from improved healthcare. Developing joint clinics to share knowledge and resources between diabetes and ID practitioners may improve service delivery and continuity of care, and thereby diminish the costs of not providing quality care. © 2017 MENCAP and International Association of the Scientific Study of Intellectual and Developmental

Diabetes and Hypertension Quality Measurement in Four Safety-Net Sites

PubMed Central

Benkert, R.; Dennehy, P.; White, J.; Hamilton, A.; Tanner, C.

2014-01-01

Summary Background In this new era after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the literature on lessons learned with electronic health record (EHR) implementation needs to be revisited. Objectives Our objective was to describe what implementation of a commercially available EHR with built-in quality query algorithms showed us about our care for diabetes and hypertension populations in four safety net clinics, specifically feasibility of data retrieval, measurements over time, quality of data, and how our teams used this data. Methods A cross-sectional study was conducted from October 2008 to October 2012 in four safety-net clinics located in the Midwest and Western United States. A data warehouse that stores data from across the U.S was utilized for data extraction from patients with diabetes or hypertension diagnoses and at least two office visits per year. Standard quality measures were collected over a period of two to four years. All sites were engaged in a partnership model with the IT staff and a shared learning process to enhance the use of the quality metrics. Results While use of the algorithms was feasible across sites, challenges occurred when attempting to use the query results for research purposes. There was wide variation of both process and outcome results by individual centers. Composite calculations balanced out the differences seen in the individual measures. Despite using consistent quality definitions, the differences across centers had an impact on numerators and denominators. All sites agreed to a partnership model of EHR implementation, and each center utilized the available resources of the partnership for Center-specific quality initiatives. Conclusions Utilizing a shared EHR, a Regional Extension Center-like partnership model, and similar quality query algorithms allowed safety-net clinics to benchmark and improve the quality of care across differing patient populations and health care

Evaluation of the diabetes health plan to improve diabetes care and prevention.

PubMed

Duru, O Kenrik; Mangione, Carol M; Chan, Charles; Keckhafer, Abigail; Kimbro, Lindsay; Kirvan, K Anya; Turk, Norman; Luchs, Robert; Li, Jinnan; Ettner, Susan

2013-01-01

Investigators from the University of California, Los Angeles (UCLA), and members of the leadership and data analysis teams at UnitedHealthcare (UHC) are partnering to evaluate the Diabetes Health Plan (DHP), an innovative disease-specific insurance product designed by UHC specifically for patients with prediabetes or diabetes. The DHP provides improved access to care management, telephone coaching, and enhanced Internet-based communication with enrollees. The evaluation will use a quasi-experimental design, comparing patients from employer groups that offer the DHP with patients from groups that do not, to determine the effect of the DHP on incidence of diabetes, adherence to metformin, and costs of care among patients with prediabetes. Other factors studied will be cardiovascular risk factor control, adherence to preventive services, health care use, and costs of care among patients with existing diabetes.

Diabetes Self-Management: A Key for Better Health-related Quality of Life in Patients with Diabetes.

PubMed

Badr, Hanan E; Al-Khaledi, Maha; Al-Dousari, Hussah; Al-Dhufairi, Shaikhah; Al-Mousawi, Taiba; Al-Azemi, Rehab; Al-Azimi, Farah

2018-04-17

This study was aimed at assessing health-related quality of life (HRQOL) among adult patients with diabetes attending primary health care diabetes clinics in Kuwait and to examine the factors associated with patients with the HRQOL of patients with diabetes. This cross-sectional study was conducted among 503 patients with diabetes attending 26 primary healthcare diabetes clinics in Kuwait. A self-administered questionnaire on participants' socio-demographic and clinical characteristics, in addition to the Diabetes Self-Management Questionnaire (DSMQ) to assess patients' DSM was used. SF12 was employed to assess the HRQOL, producing two outcomes: Physical health composite and Mental health composite. The mean age of participants was 52. ± 0.8 years, 53.1% were males, and 49.0% were Kuwaitis. The median DSM sum score was 6.5. Male patients with diabetes showed significantly better median DSM sum score than female patients with diabetes. The overall median score of HRQOL was 61.7/100 with a better median score of PHC than MHC of quality of life (66.7/100 and 56.7/100, respectively). Multivariate analysis revealed a significant direct association between DSM and better primary health composite and mental health composite. It also showed that female gender, and reporting two or more diabetic complications were significantly associated with poor PHC. Kuwaiti patients with diabetes showed a modest level of HRQOL. Patients' DSM, gender, and diabetes complications were significant independent correlates to HRQOL. Appraisal of patients with diabetes' HRQOL as an essential component of diabetes management in clinical settings is suggested. Further studies to examine the impact of good diabetes self-management on HRQOL improvement are needed.

. ©2018The Author(s). Published by S. Karger AG, Basel.

Diabetes Self-Care and the Older Adult

PubMed Central

Weinger, Katie; Beverly, Elizabeth A.; Smaldone, Arlene

2014-01-01

The prevalence of diabetes is highest in older adults, a population that is increasing. Diabetes self-care is complex with important recommendations for nutrition, physical activity, checking glucose levels, and taking medication. Older adults with diabetes have unique issues which impact self-care. As people age, their health status, support systems, physical and mental abilities, and nutritional requirements change. Furthermore, comorbidities, complications, and polypharmacy complicate diabetes self-care. Depression is also more common among the elderly and may lead to deterioration in self-care behaviors. Because of concerns about cognitive deficits and multiple comorbidities, adults older than 65 years are often excluded from research trials. Thus, little clinical evidence is available and the most appropriate treatment approaches and how to best support older patients’ self-care efforts are unclear. This review summarizes the current literature, research findings, and expert and consensus recommendations with their rationales. PMID:24510969

An ICT-Based Diabetes Management System Tested for Health Care Delivery in the African Context.

PubMed

Takenga, Claude; Berndt, Rolf-Dietrich; Musongya, Olivier; Kitero, Joël; Katoke, Remi; Molo, Kakule; Kazingufu, Basile; Meni, Malikwisha; Vikandy, Mambo; Takenga, Henri

2014-01-01

The demand for new healthcare services is growing rapidly. Improving accessibility of the African population to diabetes care seems to be a big challenge in most countries where the number of care centers and medical staff is reduced. Information and communication technologies (ICT) have great potential to address some of these challenges faced by several countries in providing accessible, cost-effective, and high-quality health care services. This paper presents the Mobil Diab system which is a telemedical approach proposed for the management of long-term diseases. The system applies modern mobile and web technologies which overcome geographical barriers, and increase access to health care services. The idea of the system is to involve patients in the therapy process and motivate them for an active participation. For validation of the system in African context, a trial was conducted in the Democratic Republic of Congo. 40 Subjects with diabetes divided randomly into control and intervention groups were included in the test. Results show that Mobil Diab is suitable for African countries and presents a number of benefits for the population and public health care system. It improves clinical management and delivery of diabetes care services by enhancing access, quality, motivation, reassurance, efficiency, and cost-effectiveness.

An ICT-Based Diabetes Management System Tested for Health Care Delivery in the African Context

PubMed Central

Takenga, Claude; Berndt, Rolf-Dietrich; Musongya, Olivier; Kitero, Joël; Katoke, Remi; Molo, Kakule; Kazingufu, Basile; Meni, Malikwisha; Vikandy, Mambo; Takenga, Henri

2014-01-01

The demand for new healthcare services is growing rapidly. Improving accessibility of the African population to diabetes care seems to be a big challenge in most countries where the number of care centers and medical staff is reduced. Information and communication technologies (ICT) have great potential to address some of these challenges faced by several countries in providing accessible, cost-effective, and high-quality health care services. This paper presents the Mobil Diab system which is a telemedical approach proposed for the management of long-term diseases. The system applies modern mobile and web technologies which overcome geographical barriers, and increase access to health care services. The idea of the system is to involve patients in the therapy process and motivate them for an active participation. For validation of the system in African context, a trial was conducted in the Democratic Republic of Congo. 40 Subjects with diabetes divided randomly into control and intervention groups were included in the test. Results show that Mobil Diab is suitable for African countries and presents a number of benefits for the population and public health care system. It improves clinical management and delivery of diabetes care services by enhancing access, quality, motivation, reassurance, efficiency, and cost-effectiveness. PMID:25136358

Preconception care for women with type 1 or type 2 diabetes mellitus: a mixed-methods study exploring uptake of preconception care.

PubMed

Earle, Sarah; Tariq, Anisah; Komaromy, Carol; Lloyd, Cathy E; Karamat, M Ali; Webb, Jackie; Gill, Paramjit S

2017-03-01

Diabetes mellitus is a global health problem and one of the most common medical conditions in pregnancy. A wide range of modifiable risk factors are associated with diabetes mellitus in pregnancy, and it is widely acknowledged that preconception care (PCC) is beneficial for women with pre-existing diabetes mellitus. However, uptake of PCC services is low. To systematically review qualitative research on PCC for women with pre-existing diabetes mellitus of childbearing age, identify facilitators of and barriers to uptake of PCC and establish themes and gaps in knowledge. Through qualitative interviews explore views on the provision of, and facilitators of and barriers to the uptake of, PCC. Mixed methods encompassing a systematic review and qualitative interviews. Two secondary care sites and 11 primary care sites. Women of childbearing age with pre-existing type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) of white British or Pakistani origin. None. A narrative synthesis of the literature using thematic analysis and a thematic analysis of the qualitative interview data using the method of constant comparison. Eighteen qualitative studies were included in the systematic review and a quality appraisal was carried out using relevant criteria for qualitative research appraisal, including a narrative summary of study quality. Twelve interviews with women with pre-existing T1DM or T2DM were carried out. This fell short of the original aim of interviewing 48 women owing to challenges in recruitment, especially in primary care. A synthesis of these data shows that uptake of PCC is influenced by a range of factors, including the complexity of pregnancy planning, the skill and expertise of health professionals who provide care to women with diabetes mellitus, the role of health professionals in the delivery of PCC, and the quality of relationships between women and health professionals. Owing to significant challenges with recruitment of participants

Evaluation of a program to improve diabetes care through intensified care management activities and diabetes medication copayment reduction.

PubMed

Kogut, Stephen J; Johnson, Scott; Higgins, Tara; Quilliam, Brian

2012-05-01

for intervention than comparison patients (means [SDs] of $3,139 [$3,426] vs. $2,854 [$3,938], respectively, P < 0.001); and the generic-dispensing ratio was slightly lower (means [SDs] of 62.1% [22.4%] and 65.4% [23.0%], respectively, P < 0.001). There were no significant differences between the intervention and comparison groups in mean [SD] PPPY all-cause medical care costs ($7,475 [$17,601] vs. $8,577 [$22,972], respectively, P = 0.213) or total all-cause costs ($10,613 [$18,590] vs. $11,431 [$24,060], P = 0.666). Patients participating in this incentive program featuring diabetes medication copayment reduction and disease management components did not receive recommended care any more or less frequently than other enrolled members with diabetes. Younger patients and those utilizing oral antidiabetic monotherapy as their drug regimens were less likely to have the recommended processes of care performed. While prescription drug expenditures incurred by the plan were greater for intervention patients, between-group differences in total costs for medications and all-cause medical care were not statistically significant. Further follow-up is required to determine the success of this program over the longer term in promoting quality of care and achieving cost reductions and improved health outcomes.

Diabetes knowledge in nursing homes and home-based care services: a validation study of the Michigan Diabetes Knowledge Test adapted for use among nursing personnel.

PubMed

Haugstvedt, Anne; Aarflot, Morten; Igland, Jannicke; Landbakk, Tilla; Graue, Marit

2016-01-01

Providing high-quality diabetes care in nursing homes and home-based care facilities requires suitable instruments to evaluate the level of diabetes knowledge among the health-care providers. Thus, the aim of this study was to examine the psychometric properties of the Michigan Diabetes Knowledge Test adapted for use among nursing personnel. The study included 127 nursing personnel (32 registered nurses, 69 nursing aides and 26 nursing assistants) at three nursing homes and one home-based care facility in Norway. We examined the reliability and content and construct validity of the Michigan Diabetes Knowledge Test. The items in both the general diabetes subscale and the insulin-use subscale were considered relevant and appropriate. The instrument showed satisfactory properties for distinguishing between groups. Item response theory-based measurements and item information curves indicate maximum information at average or lower knowledge scores. Internal consistency and the item-total correlations were quite weak, indicating that the Michigan Diabetes Knowledge Test measures a set of items related to various relevant knowledge topics but not necessarily related to each other. The Michigan Diabetes Knowledge Test measures a broad range of topics relevant to diabetes care. It is an appropriate instrument for identifying individual and distinct needs for diabetes education among nursing personnel. The knowledge gaps identified by the Michigan Diabetes Knowledge Test could also provide useful input for the content of educational activities. However, some revision of the test should be considered.

Getting the Very Best Care for Your Diabetes

MedlinePlus

... with diabetes. Most of the day-to-day care of diabetes is up to you: • You choose what, when, ... 15 Toolkit No. 17: Getting the Very Best Care for Your Diabetes continued Tracking your targets The ADA suggests these ...

German diabetes management programs improve quality of care and curb costs.

PubMed

Stock, Stephanie; Drabik, Anna; Büscher, Guido; Graf, Christian; Ullrich, Walter; Gerber, Andreas; Lauterbach, Karl W; Lüngen, Markus

2010-12-01

This paper reports the results of a large-scale analysis of a nationwide disease management program in Germany for patients with diabetes mellitus. The German program differs markedly from "classic" disease management in the United States. Although it combines important hallmarks of vendor-based disease management and the Chronic Care Model, the German program is based in primary care practices and carried out by physicians, and it draws on their personal relationships with patients to promote adherence to treatment goals and self-management. After four years of follow-up, overall mortality for patients and drug and hospital costs were all significantly lower for patients who participated in the program compared to other insured patients with similar health profiles who were not in the program. These results suggest that the German disease management program is a successful strategy for improving chronic illness care.

Improvements in diabetes processes of care and intermediate outcomes: United States, 1988-2002.

PubMed

Saaddine, Jinan B; Cadwell, Betsy; Gregg, Edward W; Engelgau, Michael M; Vinicor, Frank; Imperatore, Giuseppina; Narayan, K M Venkat

2006-04-04

Progress of diabetes care is a subject of public health concern. To assess changes in quality of diabetes care in the United States by using standardized measures. National population-based, serial cross-sectional surveys. National Health and Nutrition Examination Survey (1988-1994 and 1999-2002) and the Behavioral Risk Factor Surveillance System (1995 and 2002). Survey participants 18 to 75 years of age who reported a diagnosis of diabetes. Glycemic control, blood pressure, low-density lipoprotein (LDL) cholesterol level, annual cholesterol level monitoring, and annual foot and dilated eye examination, as defined by the National Diabetes Quality Improvement Alliance measures. In the past decade, the proportion of persons with diabetes with poor glycemic control (hemoglobin A1c > 9%) showed a nonstatistically significant decrease of 3.9% (95% CI, -10.4% to 2.5%), while the proportion of persons with fair or good lipid control (LDL cholesterol level < 3.4 mmol/L [<130 mg/dL]) had a statistically significant increase of 21.9% (CI, 12.4% to 31.3%). Mean LDL cholesterol level decreased by 0.5 mmol/L (18.8 mg/dL). Although mean hemoglobin A1c did not change, the proportion of persons with hemoglobin A(1c) of 6% to 8% increased from 34.2% to 47.0%. The blood pressure distribution did not change. Annual lipid testing, dilated eye examination, and foot examination increased by 8.3% (CI, 4.0% to 12.7%), 4.5% (CI, 0.5% to 8.5%), and 3.8% (CI, -0.1% to 7.7%), respectively. The proportion of persons reporting annual influenza vaccination and aspirin use improved by 6.8 percentage points (CI, 2.9 percentage points to 10.7 percentage points) and 13.1 percentage points (CI, 5.4 percentage points to 20.7 percentage points), respectively. Data are self-reported, and the surveys do not have all National Diabetes Quality Improvement Alliance indicators. Diabetes processes of care and intermediate outcomes have improved nationally in the past decade. But 2 in 5 persons with diabetes

Communication Strategies for Improving Diabetics' Self-Care.

ERIC Educational Resources Information Center

Pryor, Burt; Mengel, Marvin C.

1987-01-01

Focuses on various levels of diabetic patients' involvement in the care of their disease and effects of these levels on how closely they later followed self-care programs. Suggests that by participating in group discussions about excuses for not following a self-care regimen, and offering solutions to counter those excuses, diabetic patients…

Working Together to Promote Diabetes Control: A Practical Guide for Diabetes Health Care Providers in Establishing a Working Alliance to Achieve Self-Management Support.

PubMed

Jones, Allan; Vallis, Michael; Cooke, Debbie; Pouwer, François

2016-01-01

The quality of the "patient-carer" relationship is the foundation of self-management support and has been shown to influence treatment outcome in relation to psychological and somatic illness, including diabetes. It has long been accepted within applied psychology that the quality of the client-therapist relationship--termed the working alliance--is of central importance to treatment outcome and may account for a significant degree of the overall treatment effect. Diabetes healthcare providers have recently expressed a need for further training in communication techniques and in the psychological aspects of diabetes. Could we take a page from the psychological treatment manual on working alliance in therapy to guide the diabetes healthcare provider in their role of supporting the person with diabetes achieve and maintain better metabolic control? This paper examines the role of the working alliance in diabetes care and offers a practical guide to the diabetes healthcare provider in establishing a working alliance with the person with diabetes in managing diabetes.

Primary Care Provider Perceptions of the Effectiveness of Two Self-Management Support Programs for Vulnerable Patients with Diabetes

PubMed Central

Ratanawongsa, Neda; Bhandari, Vijay K; Handley, Margaret; Rundall, Thomas; Hammer, Hali; Schillinger, Dean

2012-01-01

Background Primary care providers (PCPs) in safety net settings face barriers to optimizing care for patients with diabetes. We conducted this study to assess PCPs' perspectives on the effectiveness of two language-concordant diabetes self-management support programs. Methods One year postintervention, we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic randomized controlled trial comparing usual care (UC), weekly automated telephone self-management (ATSM) support with nurse care management, and monthly group medical visits (GMVs). We compared PCP perspectives on patient activation to create and achieve goals, quality of care, and barriers to care using regression models accounting for within-PCP clustering. Results Of 113 eligible PCPs caring for 330 enrolled patients, 87 PCPs (77%) responded to surveys about 245 (74%) enrolled patients. Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients (standardized effect size, ATSM vs UC, +0.41, p = 0.01; GMV vs UC, +0.31, p = 0.05). Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC (odds ratio 3.6, p < 0.01). Compared with GMV patients, ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency (82% ATSM vs 44% GMV, p = 0.01) and managing medications (80% ATSM vs 53% GMV, p = 0.01). Conclusions Primary care providers perceived that patients receiving ATSM support had overcome barriers, participated more actively, and received higher quality diabetes care. These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse, multilinguistic populations. PMID:22401329

[Better coordination between primary care, community settings and diabetes outpatient clinic for patients with type 2 diabetes].

PubMed

Gjessing, Hans Jørgen; Jørgensen, Ulla Linding; Møller, Charlotte Chrois; Huge, Lis; Dalgaard, Anne Mette; Nielsen, Kristian Wendelboe; Thomsen, Lis; Buch, Martin Sandberg

2014-06-02

Integrated care programmes for patients with type 2 diabetes can be successfully implemented by planning the programmes in coordination between the sectors primary care, community settings and diabetes outpatient clinic, and with involvement of leaders and employees. Our project has resulted in: 1) more patients with type 2 diabetes receiving diabetes management courses, 2) improved diabetes management of primary care, and 3) improved confidence and respect between sectors involved in diabetes care.

Impact of primary care-based disease management on the health-related quality of life in patients with type 2 diabetes and comorbidity.

PubMed

Ose, Dominik; Wensing, Michel; Szecsenyi, Joachim; Joos, Stefanie; Hermann, Katja; Miksch, Antje

2009-09-01

This study examined the effectiveness of the German diabetes disease management program (DMP) for patients with varying numbers of other medical conditions with respect to their health-related quality of life (HRQoL). A questionnaire, including the HRQoL-measured EQ-5D, was mailed to a random sample of 3,546 patients with type 2 diabetes (59.3% female). The EQ-5D score was analyzed by grouping patients according to those on a DMP and those receiving routine care. The analysis showed that participation in the DMP (P < 0.001), the number of other medical conditions (P < 0.001), and the interaction between the DMP and the number of other conditions (P < 0.05) had a significant impact on the EQ-5D score. Our findings suggest that the number of other medical conditions may have a negative impact on the HRQoL of patients with type 2 diabetes. The results demonstrate that the German DMP for type 2 diabetes may help counterbalance this effect.

Pharmacist managed diabetes and cardiovascular risk reduction clinic in kidney transplant recipients: bridging the gap in care transition.

PubMed

Pinelli, Nicole R; Clark, Lindsey M; Carrington, Anne C; Carrington, Julia L; Malinzak, Lauren; Patel, Anita

2014-12-01

The purpose was to assess the feasibility of a care transition intervention for kidney transplant recipients (KTRs) with diabetes. Results document improved quality indicators and reduced resource utilization. These findings imply that a care transition intervention for KTRs with diabetes is feasible and associated with improved patient outcomes. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Impact of care management processes and integration of care on blood pressure control in diabetes.

PubMed

Wong, Ken; Boulanger, Luke; Smalarz, Amy; Wu, Ning; Fraser, Kimberly; Wogen, Jenifer

2013-02-27

Fragmentation within health care systems may negatively impact the quality of chronic disease patient care. We sought to evaluate the relationship between care management processes (CMP), integration of services, and blood pressure (BP) control among diabetic patients. Retrospective chart reviews were performed for a random sample of adult diabetic hypertensive patients (n = 2,162) from 28 physician organizations in the United States (US). A modified version of the Physician Practice Connection Readiness Survey (PPC-RS) was completed by the chief medical officer at each site. The PPC-RS measured health system organization, delivery system redesign, decision support, clinical information systems, and self-management support, and an integration scale measured structure, functions, and financial risk. Correlations between PPC and integration scores and BP outcomes were assessed using Spearman correlation coefficients. Approximately 39.9% of diabetic patients had controlled BP. Mean total PPC score across sites was 55, with highest mean scores for health system organization (81), followed by design support (60), clinical information systems (57), self-management support (39), and delivery system redesign (39). Mean integration score was 46 (SD 27, range 4-93), and means of subscores were 64 for structure, 33 for financial risk, and 42 for function. Clinical information systems subscore was correlated with uncontrolled BP (r = -0.38, p < 0.05), while association with total PPC score was strong but not significant at p < 0.05 (r = -0.32). Total integration score and the structure subscore were significantly correlated with BP control (r = 0.38, p < 0.05, and r = 0.49, p < 0.01). This study suggests that CMP and service integration may be associated with better outcomes in diabetes, though results were mixed and limited by a small number of participating sites. Primary care implementation of integrated electronic medical records may have a beneficial effect on patient

Reducing racial/ethnic disparities in diabetes: the Coached Care (R2D2C2) project.

PubMed

Kaplan, Sherrie H; Billimek, John; Sorkin, Dara H; Ngo-Metzger, Quyen; Greenfield, Sheldon

2013-10-01

Despite numerous efforts to change healthcare delivery, the profile of disparities in diabetes care and outcomes has not changed substantially over the past decade. To understand potential contributors to disparities in diabetes care and glycemic control. Cross sectional analysis. Seven outpatient clinics affiliated with an academic medical center. Adult patients with type 2 diabetes who were Mexican American, Vietnamese American or non-Hispanic white (n = 1,484). Glycemic control was measured as hemoglobin A1c (HbA1c) level. Patient, provider and system characteristics included demographic characteristics; access to care; quality of process of care including clinical inertia; quality of interpersonal care; illness burden; mastery (diabetes management confidence, passivity); and adherence to treatment. Unadjusted HbA1c values were significantly higher for Mexican American patients (n = 782) (mean = 8.3 % [SD:2.1]) compared with non-Hispanic whites (n = 389) (mean = 7.1 % [SD:1.4]). There were no significant differences in HbA1c values between Vietnamese American and non-Hispanic white patients. There were no statistically significant group differences in glycemic control after adjustment for multiple measures of access, and quality of process and interpersonal care. Disease management mastery and adherence to treatment were related to glycemic control for all patients, independent of race/ethnicity. Generalizability to other minorities or to patients with poorer access to care may be limited. The complex interplay among patient, physician and system characteristics contributed to disparities in HbA1c between Mexican American and non-Hispanic white patients. In contrast, Vietnamese American patients achieved HbA1c levels comparable to non-Hispanic whites and adjustment for numerous characteristics failed to identify confounders that could have masked disparities in this subgroup. Disease management mastery appeared to be an important contributor

The Utah Beacon Experience: Integrating Quality Improvement, Health Information Technology, and Practice Facilitation to Improve Diabetes Outcomes in Small Health Care Facilities

PubMed Central

Tennison, Janet; Rajeev, Deepthi; Woolsey, Sarah; Black, Jeff; Oostema, Steven J.; North, Christie

2014-01-01

Purpose: The Utah Improving Care through Connectivity and Collaboration (IC3) Beacon community (2010–2013) was spearheaded by HealthInsight, a nonprofit, community-based organization. One of the main objectives of IC3 was to improve health care provided to patients with diabetes in three Utah counties, collaborating with 21 independent smaller clinics and two large health care enterprises. This paper will focus on the use of health information technology (HIT) and practice facilitation to develop and implement new care processes to improve clinic workflow and ultimately improve patients’ diabetes outcomes at 21 participating smaller, independent clinics. Innovation: Early in the project, we learned that most of the 21 clinics did not have the resources needed to successfully implement quality improvement (QI) initiatives. IC3 helped clinics effectively use data generated from their electronic health records (EHRs) to design and implement interventions to improve patients’ diabetes outcomes. This close coupling of HIT, expert practice facilitation, and Learning Collaboratives was found to be especially valuable in clinics with limited resources. Findings: Through this process we learned that (1) an extensive readiness assessment improved clinic retention, (2) clinic champions were important for a successful collaboration, and (3) current EHR systems have limited functionality to assist in QI initiatives. In general, smaller, independent clinics lack knowledge and experience with QI and have limited HIT experience to improve patient care using electronic clinical data. Additionally, future projects like IC3 Beacon will be instrumental in changing clinic culture so that QI is integrated into routine workflow. Conclusion and Discussion: Our efforts led to significant changes in how practice staff optimized their EHRs to manage and improve diabetes care, while establishing the framework for sustainability. Some of the IC3 Beacon practices are currently smoothly

Synthesis: Deriving a Core Set of Recommendations to Optimize Diabetes Care on a Global Scale.

PubMed

Mechanick, Jeffrey I; Leroith, Derek

2015-01-01

Diabetes afflicts 382 million people worldwide, with increasing prevalence rates and adverse effects on health, well-being, and society in general. There are many drivers for the complex presentation of diabetes, including environmental and genetic/epigenetic factors. The aim was to synthesize a core set of recommendations from information from 14 countries that can be used to optimize diabetes care on a global scale. Information from 14 papers in this special issue of Annals of Global Health was reviewed, analyzed, and sorted to synthesize recommendations. PubMed was searched for relevant studies on diabetes and global health. Key findings are as follows: (1) Population-based transitions distinguish region-specific diabetes care; (2) biological drivers for diabetes differ among various populations and need to be clarified scientifically; (3) principal resource availability determines quality-of-care metrics; and (4) governmental involvement, independent of economic barriers, improves the contextualization of diabetes care. Core recommendations are as follows: (1) Each nation should assess region-specific epidemiology, the scientific evidence base, and population-based transitions to establish risk-stratified guidelines for diagnosis and therapeutic interventions; (2) each nation should establish a public health imperative to provide tools and funding to successfully implement these guidelines; and (3) each nation should commit to education and research to optimize recommendations for a durable effect. Systematic acquisition of information about diabetes care can be analyzed, extrapolated, and then used to provide a core set of actionable recommendations that may be further studied and implemented to improve diabetes care on a global scale. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Are Characteristics of the Medical Home Associated with Diabetes Care Costs?

PubMed Central

Flottemesch, Thomas J.; Scholle, Sarah Hudson; O’Connor, Patrick J.; Solberg, Leif I.; Asche, Steve; Pawlson, L. Gregory

2015-01-01

Objective To examine the relationship between primary care medical home clinical practice systems (PCMH clinical practice systems) corresponding to the domains of the Chronic Care Model and diabetes-related healthcare costs incurred by members of a health plan who have diagnosed Type 2 diabetes and received care at one of 27 Minnesota-based medical groups over a 12-month period. Study Design Cross-sectional analysis of patient-level cost data in relation to the presence of PCMH clinical practice systems by Chronic Care Model domain using the Physician Practice Connections Readiness Survey (PPC-RS). Methods Multivariate regressions adjusting for patient demographics, health status and comorbidities estimated the relationship between the presence of PCMH clinical practice systems as measured by the PPC-RS and three outcomes: total diabetes-related healthcare costs, ambulatory care management costs, and potentially avoidable costs (e.g. unscheduled inpatient and emergency care). Results Two domains of PCMH clinical practice systems as measured by the PPC-RS were significantly associated with reductions in potentially avoidable costs. These were Health Care Organization (p=.04) and clinical reminder systems in the Decision Support domain (p=.01). Compared to medical groups with only quality improvement, those with improved Health Care Organization defined as performance measurement and individual provider feedback averaged $245/patient less. Similarly, medical groups with clinical reminders for counseling averaged $338/patient less. Conclusions PCMH clinical practice systems that correspond to some domains of the Chronic Care Model are related to reduced inpatient and emergency care costs. Further research is needed about how these systems impact costs over time. PMID:22710277

Health communication, self-care, and treatment satisfaction among low-income diabetes patients in a public health setting.

PubMed

White, Richard O; Eden, Svetlana; Wallston, Kenneth A; Kripalani, Sunil; Barto, Shari; Shintani, Ayumi; Rothman, Russell L

2015-02-01

Diabetes patients with limited resources often experience suboptimal care. Less is known about the role of effective health communication (HC) in caring for low income diabetes patients. Ten health department clinics in TN participated in a trial evaluating a literacy-sensitive communication intervention. We assessed the quality of baseline HC and measured associations with diabetes outcomes. Assessments included: demographics, measures of HC, health literacy, self-care behaviors, self-efficacy, medication non-adherence, treatment satisfaction, and A1C. Unadjusted and adjusted multivariable regression models were used to test associations. Participants (N=411) were 49.7±9.5 years, 61% female, uninsured (96%), with A1C 9.6±2.1. In unadjusted analyses, better communication, was associated with lower medication non-adherence (OR 0.40-0.68, all p<0.05), higher treatment satisfaction (OR 1.76-1.96, all p<0.01), portion size reduction (OR 1.43, p<0.05), diabetes self-efficacy (OR 1.41, p<0.05), and lower A1C (β=-0.06, p<0.01). In adjusted analyses, communication quality remained associated with lower medication non-adherence (AOR 0.39-0.68, all p<0.05), and higher treatment satisfaction (AOR 1.90-2.21, all p<0.001). Better communication between low-income patients and providers was independently associated with lower medication non-adherence and higher treatment satisfaction. Communication quality may be an important modifiable approach to improving diabetes care for vulnerable populations. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Implementing elements of a context-adapted chronic care model to improve first-line diabetes care: effects on assessment of chronic illness care and glycaemic control among people with diabetes enrolled to the First-Line Diabetes Care (FiLDCare) Project in the Northern Philippines.

PubMed

Ku, Grace M V; Kegels, Guy

2015-09-01

Aim The purpose of this study was to investigate the effects of implementing elements of a context-adapted chronic disease-care model (CACCM) in two local government primary healthcare units of a non-highly urbanized city and a rural municipality in the Philippines on Patients' Assessment of Chronic Illness Care (PACIC) and glycaemic control (HbA1c) of people with diabetes. Low-to-middle income countries like the Philippines are beset with rising prevalence of chronic conditions but their healthcare systems are still acute disease oriented. Attention towards improving care for chronic conditions particularly in primary healthcare is imperative and ways by which this can be done amidst resource constraints need to be explored. A chronic care model was adapted based on the context of the Philippines. Selected elements (community sensitization, decision support, minor re-organization of health services, health service delivery-system re-design, and self-management education and support) were implemented. PACIC and HbA1c were measured before and one year after the start of implementation. Findings The improvements in the PACIC (median, from 3.2 to 3.5) as well as in four of the five subsets of the PACIC were statistically significant (P-values: PACIC=0.009; 'patient activation'=0.026; 'goal setting'=0.017; 'problem solving'<0.001; 'follow-up'<0.001). The decrease in HbA1c (median, from 7.7% to 6.9%) and the level of diabetes control of the project participants (increase of optimally controlled diabetes from 37.2% to 50.6%) were likewise significant (P<0.000 and P=0.014). A significantly higher rating of the post-implementation PACIC subsets 'problem solving' (P=0.027) and 'follow-up' (P=0.025) was noted among those participants whose HbA1c improved. The quality of chronic care in general and primary diabetes care in particular may be improved, as measured through the PACIC and glycaemic control, in resource-constrained settings applying selected elements of a CACCM and

The Diabetes Symptom Self-Care Inventory: Development and Psychometric Testing with Mexican Americans

PubMed Central

García, Alexandra A.

2010-01-01

Context Type 2 diabetes is prevalent throughout the world. In previous studies of Mexican Americans with type 2 diabetes, 95-97% of those sampled reported having symptoms they believe were caused by diabetes and most self-treated their symptoms. To more accurately capture Mexican Americans’ symptom prevalence and their self-treatments, the Diabetes Symptom Self-Care Instrument (DSSCI) was adapted from the Diabetes Self-Care Instrument. Objectives This paper describes the modification process used to perfect the DSSCI for use in improving self-care among people with Type 2 diabetes. Methods This instrumentation study used qualitative and quantitative methods. The study was completed in four phases that used focus groups, cognitive interviews, and survey administration. Four convenience samples were drawn from community-based Mexican American adults, aged 25-75, with type 2 diabetes in an urban area and a rural location in Texas. Results Phase I: Seven focus groups (n=45) generated data for revising items. Phase II: Cognitive interviews with 16 participants were used to evaluate four revisions of the questionnaire. Phase III: Surveys were administered to 81 participants. Total number of symptoms on the DSSCI correlated with scores on the Centers for Epidemiological Studies-Depression scale (r=.65, p < .001), Illness Perception Questionnaire-Revised Diabetes symptom subscale (r=.57, p < .001), and Audit of Diabetes-Dependent Quality of Life scale (r= -.42, p < .001). Minor revisions followed. Phase IV: Test-retest stability was demonstrated (n = 44). Conclusion The DSSCI is a culturally-relevant, sound measure of Mexican Americans’ diabetes symptoms and the actions they take to address them. PMID:21276705

The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review

PubMed Central

Stellefson, Michael; Stopka, Christine

2013-01-01

Introduction The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation. Methods We conducted a literature review by using the Cochrane database of systematic reviews, CINAHL, and Health Source: Nursing/Academic Edition and the following search terms: “chronic care model” (and) “diabet*.” We included articles published between January 1999 and October 2011. We summarized details on CCM application and health outcomes for 16 studies. Results The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices. We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care. Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes. Only 7 studies described strategies for addressing community resources and policies. Conclusion CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. PMID:23428085