Adherence to national diabetes guidelines through monitoring quality indicators--A comparison of three types of care for the elderly with special emphasis on HbA1c

Glycaemic control of Type 2 diabetes in older patients visiting general practitioners: An examination of electronic medical records to identify risk factors for poor control

OBJECTIVE

To investigate factors associated with glycaemic control of diabetes in older patients in the general practice setting in metropolitan Melbourne, Australia.

METHOD

This retrospective study used the data from 10,257 patients aged ≥ 65 years with Type 2 diabetes from the Melbourne East Monash General Practice Database (MAGNET), 2009-2014. Poor glycaemic control was defined as HbA1c ≥ 9.0%. Univariate and multivariate analyses were conducted to assess the association between risk factors and glycaemic control.

RESULTS

Of the total 10,257 patients, 6819 (66.5%) had their HbA1c recorded within a period of 2 years prior to their last GP visit. Between 4% and 6% had HbA1c level ≥ 9.0%. Robust predictors of poor glycaemic control were found to be decreasing age group (OR = 0.77, 95% CI: 0.65-0.90) and prescribed insulin (OR = 2.83, 95% CI: 2.41-3.32).

CONCLUSION

One third of older patients with Type 2 diabetes did not have HbA1c recorded in the previous 2 years, despite clinical guidelines recommending at least annual testing. Many older patients had good glycaemic control, however the findings indicate that those aged 65-74 and those prescribed insulin may require special care and management to achieve this.

Integrative review: Patient safety among older people with diabetes in home care services

AIMS

To identify diabetes specific patient safety domains that need to be addressed to improve home care of older people; to assess research from primary studies to review evidence on patient safety in home care services for older people with diabetes.

DESIGN

An integrative review.

DATA SOURCES

Domains for patient safety in diabetes home care settings were identified by conducting two searches. We performed searches in: CINAHL, Medline, Embase, and Cochrane Library for the years 2000-2017.

REVIEW METHODS

The first search identified frameworks or models on patient safety in home care services published up to October 2017. The second search identified primary studies about older people with diabetes in the home care setting published between 2000-2017.

RESULTS

Data from the 21 articles populated and refined 13 predetermined domains of patient safety in diabetes home care. These were used to explore how the domains interact to either increase or reduce risk. The domains constitute a model of associations between aspects of diabetes home care and adverse events. The results highlight a knowledge gap in safety for older persons with diabetes, influenced by e.g. hypoglycaemia, falls, pain, foot ulcers, cognitive impairment, depression, and polypharmacy. Moreover, providers' inadequate diabetes-specific knowledge and assessment skills contribute to the risk of adverse events.

CONCLUSION

Older persons with diabetes in home care are at risk of adverse events due to their reduced ability to self-manage their condition, adverse medication effects, the family's ability to take responsibility or home care service's suboptimal approaches to diabetes care.

Mismatch between ADA and AGS recommendations for glycated hemoglobin targets for older adults

In recent years, modified glycemic targets have been defined for older adults with diabetes mellitus. In a sample of elderly patients, we have identified several inconsistencies between the real life applicability of glycated hemoglobin goals recommended by the American Diabetes Association and the American Geriatrics Society.

Quality indicators for community care for older people: A systematic review

Background

Health care systems that succeed in preventing long term care and hospital admissions of frail older people may substantially save on their public spending. The key might be found in high-quality care in the community. Quality Indicators (QIs) of a sufficient methodological level are a prerequisite to monitor, compare, and improve care quality. This systematic review identified existing QIs for community care for older people and assessed their methodological quality.

Methods

Relevant studies were identified by searches in electronic reference databases and selected by two reviewers independently. Eligible publications described the development or application of QIs to assess the quality of community care for older people. Information about the QIs, the study sample, and specific setting was extracted. The methodological quality of the QI sets was assessed with the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. A score of 50% or higher on a domain was considered to indicate high methodological quality.

Results

Searches resulted in 25 included articles, describing 17 QI sets with 567 QIs. Most indicators referred to care processes (80%) and measured clinical issues (63%), mainly about follow-up, monitoring, examinations and treatment. About two-third of the QIs focussed on specific disease groups. The methodological quality of the indicator sets varied considerably. The highest overall level was achieved on the domain ‘Additional evidence, formulation and usage’ (51%), followed by ‘Scientific evidence’ (39%) and ‘Stakeholder involvement’ (28%).

Conclusion

A substantial number of QIs is available to assess the quality of community care for older people. However, generic QIs, measuring care outcomes and non-clinical aspects are relatively scarce and most QI sets do not meet standards of high methodological quality. This study can support policy makers and clinicians to navigate through a large number of QIs and select QIs for their purposes.

PROSPERO Registration: 2014:CRD42014007199

Investigating the behavioural effects of a mobile-phone based home telehealth intervention in people with insulin-requiring diabetes: Results of a randomized controlled trial with patient interviews

Introduction

Evidence supporting home telehealth effects on clinical outcomes in diabetes is available, yet mechanisms of action for these improvements remain poorly understood. Behavioural change is one plausible explanation. This study investigated the behavioural effects of a mobile-phone based home telehealth (MTH) intervention in people with diabetes. It was hypothesized that MTH would improve self-efficacy, illness beliefs, and diabetes self-care.

Methods

A randomized controlled trial compared standard care to standard care supplemented with MTH (self-monitoring, data transmission, graphical and nurse-initiated feedback, educational calls). Self-report measures of self-efficacy, illness beliefs, and self-care were repeated at baseline, three months, and nine months. MTH effects were based on the group by time interactions in hierarchical linear models and effect sizes with 95% confidence intervals (CIs). Interviews with MTH participants explored the perceived effects of MTH on diabetes self-management.

Results

Eighty-one participants were randomized to the intervention ( n = 45) and standard care ( n = 36). Significant group by time effects were observed for five out of seven self-efficacy subscales. Effect sizes were large, particularly at nine months. Interaction effects for illness beliefs and self-care were non-significant, but effect sizes and confidence intervals suggested MTH may positively affect diet and exercise. In interviews, MTH was associated with increased awareness, motivation, and a greater sense of security. Improved self-monitoring and diet were reported by some participants.

Discussion

MTH empowers people with diabetes to manage their condition and may influence self-care. Future MTH research would benefit from investigating behavioural mechanisms and determining patient profiles predictive of greater behavioural effectiveness.