An initial assessment of the feasibility and effectiveness of implementing diabetes shared care system in Taiwan--some experiences from I-Lan County

Diabetes Pay-for-Performance Program Participation and Dialysis Risk in Relation to Educational Attainment: A Retrospective Cohort Study

Pay-for-performance (P4P) programs for diabetes care enable the provision of comprehensive and continuous health care to diabetic patients. However, patient outcomes may be affected by the patient's educational attainment. The present retrospective cohort study aimed to examine the effects of the educational attainment of diabetic patients on participation in a P4P program in Taiwan and the risk of dialysis. The data were obtained from the National Health Insurance Research Database of Taiwan. Patients newly diagnosed with type 2 diabetes mellitus (T2DM) aged 45 years from 2002 to 2015 were enrolled and observed until the end of 2017. The effects of their educational attainment on their participation in a P4P program were examined using the Cox proportional hazards model, while the impact on their risk for dialysis was investigated using the Cox proportional hazards model. The probability of participation in the P4P program was significantly higher in subjects with a junior high school education or above than in those who were illiterate or had only attained an elementary school education. Subjects with higher educational attainment exhibited a lower risk for dialysis. Different educational levels had similar effects on reducing dialysis risk among diabetic participants in the P4P program.

Chronic care model in the diabetes pay-for-performance program in Taiwan: Benefits, challenges and future directions

In this review, we discuss the chronic care model (CCM) in relation to the diabetes pay-for-performance (P4P) program in Taiwan. We first introduce the 6 components of the CCM and provide a detailed description of each of the activities in the P4P program implemented in Taiwan, mapping them onto the 6 components of the CCM. For each CCM component, the following three topics are described: the definition of the CCM component, the general activities implemented related to this component, and practical and empirical practices based on hospital or local government cases. We then conclude by describing the possible successful features of this P4P program and its challenges and future directions. We conclude that the successful characteristics of this P4P program in Taiwan include its focus on extrinsic and intrinsic incentives (i.e., shared care network), physician-led P4P and the implementation of activities based on the CCM components. However, due to the low rate of P4P program coverage, approximately 50% of patients with diabetes cannot enjoy the benefits of CCM-related activities or receive necessary examinations. In addition, most of these CCM-related activities are not allotted an adequate amount of incentives, and these activities are mainly implemented in hospitals, which compared with primary care providers, are unable to execute these activities flexibly. All of these issues, as well as insufficient implementation of the e-CCM model, could hinder the advanced improvement of diabetes care in Taiwan.

Factors associated with retinal screening among patients with diabetes in Taiwan

PURPOSE

The purpose of this study is to explore the factors associated with having a diabetic retinopathy exam (DRE) during the past 2 years among patients with diabetes.

METHODS

Patients visiting the eye clinic at Shin-Kong Memorial Hospital in Taipei were enrolled in this study from January to June 2009. A total of 313 patients participated in this study. Excluding patients with missing responses for more than three questions (38) yielded a final sample of 275 participants. Chi-square and Mann-Whitney U-tests were used for bivariate analysis. Multivariable logistic regression examined factors associated with having a DRE controlling for demographic and health factors.

RESULTS

Although 83% of participants said that their physician suggested DRE, only 60% were screened during the past 2 years. In response to the question about why patients did not seek a DRE exam, 43.2% reported that they did not know having this exam was necessary. In adjusted results, receiving information about the relationship between diabetes and retinopathy from medical staff and believing that diabetes could damage the vision were associated with having a DRE in the past 2 years (both P < 0.05).

CONCLUSIONS

Although most patients indicated that their physician suggested the need for eye care, a substantial percentage of patients with diabetes were not aware of the need for a regular DRE. Information about the relationship between diabetes and retinopathy and concerns about damage to vision were associated with greater likelihood of seeking a DRE. These factors should be considered to promote DR screening.

Risk Factors Associated With the Development of Nephropathy 10 Years After Diagnosis in Taiwanese Children With Juvenile-Onset Type 1 Diabetes-A Cohort Study From the CGJDES

Objective: To examine the risk factors for diabetic nephropathy (DN) 10 years after the diagnosis of juvenile-onset type 1 diabetes mellitus (T1DM) in a Taiwanese population. Research Design and Methods: This retrospective, observational, longitudinal cohort study of 224 patients with T1DM for >10 years (mean duration 12.6 years) included participants from the Chang Gung Juvenile Diabetes Eye Study Group. The patients received a T1DM diagnosis before the age of 18 years and were treated at the pediatric endocrine department of Chang Gung Memorial Hospital in Taiwan. The epidemiological and laboratory data such as age, sex, duration of diabetes, self-reported smoking, blood pressure, lipid profiles, urinalysis, and glycated hemoglobin A1c (HbA1c) levels were collected from medical records retrospectively for investigating the relationship between the clinical parameters and the development of DN in T1DM. Results: During follow-up, 44 of the 224 patients (19.6%) developed DN, of whom 61.4% were female. Cox proportional hazards model analysis indicated that the female (HR 3.40, 95% CI 1.66-6.96, p = 0.001), smoking (HR 3.60, 95% CI 1.28-10.10, p = 0.015), HbA1c level (HR 1.27, 95% CI 1.07-1.49, p = 0.005), diastolic blood pressure (HR 1.06, 95% CI 1.03-1.09, p < 0.001) were significantly correlated with DN after adjustment for multiple variables. The tight glucose control with multiple daily injections produced 49 % risk reduction (HR 0.51, 95% CI 0.26-0.98, p = 0.043). Conclusions: The risk of DN in patients with juvenile-onset T1DM 10 years after the T1DM diagnosis was increased with female, smoking, high HbA1c, diastolic blood pressure levels and attenuated by intensive therapy.

Risk factors associated with the development of retinopathy 10 yr after the diagnosis of juvenile-onset type 1 diabetes in Taiwan: a cohort study from the CGJDES

BACKGROUND

The aim of this study was to examine risk factors associated with the development of diabetic retinopathy (DR) 10 yr after the diagnosis of juvenile-onset type 1 diabetes in Taiwan.

METHODS

This retrospective cohort study of 153 individuals with type 1 diabetes for >10 yr duration (mean duration: 13.1 yr) included participants in the Chang Gung Juvenile Diabetes Eye Study. Risk factors assessed for association with DR included age, gender, age at onset and duration of diabetes, self-reported smoking, blood pressure, lipid profile, urinalysis, glycated hemoglobin (HbA1c), body mass index, spherical equivalent, and axial length of the eyeball.

RESULTS

There were 128 patients without DR and 25 patients with DR. The mean age at onset was 7.0 ± 4.0 yr (mean ± standard deviation). Cox proportional-hazards analysis showed that older-onset age (p = 0.001), higher HbA1c (p = 0.013), and higher triglyceride concentration (p = 0.015) were the strongest correlates of DR after adjustment for diabetes duration.

CONCLUSIONS

Development of retinopathy 10 yr after diagnosis in people with juvenile-onset type 1 diabetes was associated with older onset age, higher HbA1c, and higher triglyceride concentration.

Adherence to self-care behavior and glycemic effects using structured education

AIMS/INTRODUCTION

The purpose of the present study was to examine glycemic control in suboptimally controlled type 2 diabetes provided by a structured education group using the Diabetes Conversation Map™ (CM™) vs usual care in a university-based hospital primary care clinic.

MATERIALS AND METHODS

This was a randomized, pragmatic clinical trial. Patients with type 2 diabetes were randomly assigned to structured education or usual care groups. The primary outcome was the difference in the mean change of glycated hemoglobin (HbA1c) from baseline to 12 months. Secondary outcomes included the percentage achieving therapeutic HbA1c goal and self-behavioral changes.

RESULTS

A total of 245 patients were randomly assigned to two groups (CM™ group n = 121; usual care group, n = 116). The absolute reduction of HbA1c was significantly greater in the CM™ group at 3 and 6 months (Δ = -0.59% and Δ = -1.13%, P < 0.01), but the difference was no longer statistically significant at 9 and 12 months (Δ = -0.43% and Δ = -0.49%), based on an intention-to-treat analysis. A per-protocol analysis showed the significant change was maintained at 12 months (Δ = -0.67%). In the intervention group, greater percentages of patients achieved their American Association of Diabetes Educators Self-Care Behaviours™ framework (AADE7) behavioral goals at 3 months, in particular being active, problem-solving, reducing risk and health coping.

CONCLUSIONS

In type 2 diabetic patients with suboptimally controlled glucose, there were greater improvements in glucose control and self-care behavioral goals in those who underwent the CM™ education program compared with outcomes achieved in patients receiving usual care.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review

Background

The increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative.

Methods

This systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included.

Results

Of the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements.

Conclusions

While the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model’s elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0854-8) contains supplementary material, which is available to authorized users.

Team care of type 2 diabetes mellitus in Taiwan

Type 2 diabetes mellitus (T2DM) is a global health-care and national policy issue. As fluctuating glycemic control in diabetes often results in serious complications, we must encourage the diabetes educators' efforts at long-term follow-up among patients with T2DM. Therefore, certified diabetes educators (CDEs) play the most pivotal roles as life-long protectors for patients with T2DM. In the past 15 years, more than 4,000 CDEs have been trained and qualified, including health professionals such as physicians, nurses, dieticians, and pharmacists. The most important initiation of diabetes share care in Taiwan was originated in I-Lan County. Initiated to provide regional diabetes care, the name of this program is the Lan-Yang Diabetes Shared Care System. In 2006, the Taiwanese Association of Diabetes Educators (TADE) carried out a nationwide survey to evaluate the status of diabetes control in Taiwan, focusing on the "ABC" goal (A: HbA1c <7.0%, B: blood pressure <130/80 mmHg, C: LDL-cholesterol <100 mg/dl/total cholesterol <160 mg/dl). The results revealed that the percentage of patients with diabetes who fulfilled all ABC goals was only 4.1%. Five years later, in 2011, TADE compared two nationwide surveys and found total ABC attainment rates of 4.1% and 8.6%, respectively. The team-care approach to T2DM has been underway for over 20 years in Taiwan. Future interventions and treatment algorithms with team-based education should aim at preventing acute and chronic complications, which remains a long-term challenge in Taiwan.

A decade of diabetes care in Taiwan

INTRODUCTION

Diabetes is a major non-communicable chronic disease with a great impact on health, socio-economic burden, and premature mortality around the world. It has been recognized as an important public health issue for more than two decades in Taiwan, and concerted efforts to improve diabetes care started there in 1990. In facing the challenge of the diabetes burden, the progress and outcomes of diabetes health-care delivery can be studied by reviewing all related statistical data of the past decade.

METHODS

Data from annual national vital statistics, periodic surveys and audit reports collected from 2002-2012 in Taiwan were analyzed.

RESULTS

The population growth rate was 0.35%/year, with negative growth in age <40. The highest rate was 6.98%/year in age ≥80 y/o (p <0.001). The number of diabetics receiving any glucose-lowering agent during this period increased from 813,400 to 1,565,300, with an average growth rate of 6.76%/year (p <0.001). The age-specific prevalence rate divided by age group <20 y/o, 20-40 y/o, 40-60 y/o, 60-80 y/o and ≥80 y/o in 2008 was 0.08%, 0.52%, 7.64%, 20.04% and 18.67%, respectively, for men, and 0.08%, 0.80%, 5.70%, 22.44% and 23.63% for women. Accountability measures by age group, including HbA1c (A1C), lipid profile, urine albumin and eye fundus examination, showed a trend towards improvement in 2012 (89.0%, 75.6%, 41.5% and 32.1%, respectively in 2012 (p <0.001). ABC control data from 2002, 2006 and 2011 survey results indicated a trend toward an increased proportion with A1C below 7%, with 22.1%, 34.7% and 40.9%, respectively, in the oral agents group, and 13.7%, 15.4% and 15.8% in the insulin-treated group. BP below 130/80 mmHg was 24.3%, 31.1% and 37.4%, and LDL-C below 100 mg/dl was 29.4%, 33.1% and 51.2%. The premature mortality rate < age 70 y/o decreased from 15.37 to 12.97 per 100,000 from 2002 to 2012 (p = 0.005), and the proportion of premature mortality in diabetes decreased from 36.88% to 29.99% (p <0.001).

CONCLUSION

Diabetes remains the second highest cause in premature mortality, after cancer, among major non-communicable diseases in Taiwan.

Overcoming disparities in diabetes care: eight years' experience changing the diabetes care system in Changhua, Taiwan

AIMS

To enhance the universal coverage of quality diabetes care and overcome disparities in care among different care-provider levels by changing the diabetes care system in Changhua, Taiwan.

METHODS

The Changhua Diabetes Shared Care program's second stage commenced in 2004. Two levels of diabetes care were proposed to facilitate physician participation via advocating the more attainable goals of diabetes care. The empowerment processes were differentiated into hospital-level and primary-care-clinic-level. The community multidisciplinary care teams took the scale of the practices into consideration, and several measures were applied to ameliorate the shared care network. The implementation support team from the health authority initiated in-person, one-on-one contacts with physicians to tailor collaboration activities to the individual primary care settings. The program's performance (2004-2012) was evaluated according to the RE-AIM model's five dimensions.

RESULTS

There was substantial improvement in diabetes care quality across all dimensions and the proportion of attaining all goals significantly grew.

CONCLUSIONS

The program achieved its primary goal of enhancing the universal coverage of quality diabetes care and overcoming disparities among different levels of care providers.

Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan?

PURPOSE

In October 2001, a pay-for-performance (P4P) program for diabetes was implemented by the National Health Insurance (NHI), a single-payer program, in Taiwan. However, only limited information is available regarding the influence of this program on the patient's health-related quality of life. The aim of this study was to estimate the costs and consequences of enrolling patients in the P4P program from a single-payer perspective.

METHODS

A retrospective observational study of 529 diabetic patients was conducted between 2004 and 2005. The data used in the study were obtained from the National Health Interview Survey (NHIS) in Taiwan. Direct cost data were obtained from NHI claims data, which were linked to respondents in the NHIS using scrambled individual identification. The generic SF36 health instrument was employed to measure the quality-of-life-related health status and transformed into a utility index. Patients enrolled in the P4P program for at least 3 months were categorized as the P4P group. Following propensity score matching, 260 patients were included in the study. Outcomes included life-years, quality-adjusted life-years (QALYs), diabetes-related medical costs, overall medical costs, and incremental cost-effectiveness ratios (ICERs). A single-payer perspective was assumed, and costs were expressed in US dollars. Nonparametric bootstrapping was conducted to estimate confidence intervals for cost-effectiveness ratios.

RESULTS

Following matching, no significant difference was noted between two groups with regard to the patients' age, gender, education, family income, smoking status, BMI, or whether insulin was used. The P4P group had an increase of 0.08 (95 % CI 0.077-0.080) in QALYs, and the additional diabetes-related medical cost was US$422.74 (95 % CI US$413.58-US$435.05), yielding an ICER of US$5413.93 (95 % CI US$5226.83-US$5562.97) per QALY gained.

CONCLUSIONS

Our results provides decision makers with valuable information regarding the impact of the P4P program of diabetes care through a direct comparison of equivalent groups of patients receiving regular care. Under the single-payer NHI system, the use of financial incentives under the DM-P4P program may be an effective means to ensure the quality of follow-up treatment.

Evaluation of perception of insulin therapy among Chinese patients with type 2 diabetes mellitus

AIMS

To evaluate whether perception of insulin therapy differs between patients with type 2 diabetes treated with insulin and those treated with oral hypoglycaemic agents (OHAs), and to examine whether gender, education level, injection duration and mode of injection were associated with the patients' perception of insulin therapy.

METHODS

The validated Chinese version of the Insulin Treatment Appraisal Scale (ITAS) was used to evaluate the perception of insulin therapy among 100 insulin-treated patients and 100 OHA-treated patients. The higher the total score, the more negative is the appraisal.

RESULTS

The OHA-treated group had a higher mean total score (20 items), a higher mean total score for 16 negative items and a lower mean total score for four positive items than the insulin-treated group. The proportion of participants who rated the negative items as "agree" or "strongly agree" was significantly higher in the OHA-treated group than in the insulin-treated group. In addition, the proportion of participants who rated the four positive items as "agree" or "strongly agree" was lower in the OHA-treated group than in the insulin-treated group. Gender, education level, duration of insulin injection and mode of injection did not have a significant impact on perception of insulin therapy.

CONCLUSION

Chinese type 2 diabetic patients taking OHAs had more negative beliefs and attitudes towards insulin therapy than patients being treated with insulin. This difference was not associated with either gender or education level. Furthermore, neither injection duration nor type of device was related to perception of insulin therapy.

Gender differences in trends in diabetes prevalence from 1993 to 2008 in Taiwan

We examined time trends in the prevalence of diabetes using nationally representative samples, with a focus on gender differences. Data were from the Nutrition and Health Survey in Taiwan (NAHSIT), 1993-1996 (n = 2700), and NAHSIT 2004-2008 (n = 2258). Participants aged 19 years or older with adequate fasting glucose data were included. When needed, rates were standardized to the year 2000 WHO 5-year interval population for comparisons. The prevalence increased significantly in men, whose standardized rate increased from 4.6% to 9.3%. In women, the age standardized prevalence decreased slightly from 7.9% to 6.4%. High triglycerides (≥ 150 mg/dL) was associated with diabetes with odds ratios (OR) of 2.14, and 2.69 (all with p<0.05) in the two surveys. High waist circumference (men ≥ 90 cm; women ≥ 80 cm) was also associated with diabetes with ORs of 2.52, and 1.93 (all with p < 0.05). We recommend the development of innovative health promotion programs targeting not only the general population, but also high risk groups such as men, to further reduce diabetes.

The unintended consequence of diabetes mellitus pay-for-performance (P4P) program in Taiwan: are patients with more comorbidities or more severe conditions likely to be excluded from the P4P program?

OBJECTIVE

Taiwan has instituted a pay-for-performance (P4P) program for diabetes mellitus (DM) patients that rewards doctors based in part on outcomes for their DM patients. Doctors are permitted to choose which of their DM patients are included in the P4P program. We test whether seriously ill DM patients are disproportionately excluded from the P4P program.

DATA SOURCE/STUDY SETTING

This study utilizes data from the National Health Insurance (NHI) database in Taiwan for the period of January 2007 to December 2007. Our sample includes 146,481 DM-P4P patients (16.56 percent of the total) and 737,971 non-DM-P4P patients.

DATA COLLECTION/EXTRACTION METHODS

We use logistic and multilevel models to estimate the effects of patient and hospital characteristics on P4P selection.

PRINCIPAL FINDINGS

The results show that older patients and patients with more comorbidities or more severe conditions are prone to be excluded from P4P programs.

CONCLUSIONS

We found that DM patients are disproportionately excluded from P4P programs. Our results point to the importance of mandated participation and risk adjustment measures in P4P programs.

Compliance, attitudes and barriers to post-operative colorectal cancer follow-up

RATIONALE

Meta-analyses demonstrate that surveillance following curative-intent colorectal cancer (CRC) surgery can improve survival. Our multidisciplinary team adopted a stringent CRC follow-up (FU) guideline in 2000. The purpose of this study was to assess adherence and barriers to FU for CRC.

METHODS

Patients with primary CRC aged 19-75 years, treated with curative intent surgery from July 2000 to December 2002 were identified from a prospective database. Compliance with FU was assessed primarily by chart review. We also surveyed patients and providers to explore attitudes and barriers to surveillance adherence using tenets of the Health Belief Model.

RESULTS

96 patients met inclusion criteria and were appropriate for FU. Median FU was 34 months. Guideline targets were met for 70% of clinic visits; 49% of carcinoembryonic antigen (CEA) determinations; and 62% of abdominal imaging studies. Post-operative colonoscopy did not occur in 6/93 patients. Seventy per cent of health care providers and 55% of patients completed a survey. Access to testing and confusion about which provider orders investigations were identified as important barriers to FU.

CONCLUSION

Patterns of CRC FU were widely variable despite implementation of a guideline. Despite patient and provider agreement with the principles of CRC FU, adoption was inhibited by confusion among multiple providers regarding investigation coordination.

Are we measuring what matters in health technology assessment of disease management? Systematic literature review

OBJECTIVES

An overview was produced of indicators currently used to assess disease management programs and, based on these findings, provide a framework regarding sets of indicators that should be used when taking the aims and types of disease management programs into account.

METHODS

A systematic literature review was performed.

RESULTS

Thirty-six studies met the inclusion criteria. It appeared that a link between aims of disease management and evaluated structure, process, as well as outcome indicators does not exist in a substantial part of published studies on disease management of diabetes and asthma/chronic obstructive pulmonary disease, especially when efficiency of care is concerned. Furthermore, structure indicators are largely missing from the evaluations, although these are of major importance for the interpretation of outcomes for purposes of decision-making. Efficiency of disease management is mainly evaluated by means of process indicators; the use of outcome indicators is less common. Within a framework, structure, process, and outcome indicators for effectiveness and efficiency are recommended for each type of disease management program.

CONCLUSIONS

The link between aims of disease management and evaluated structure, process, and outcome indicators does not exist in a substantial part of published studies on disease management. The added value of this study mainly lies in the development of a framework to guide the choice of indicators for health technology assessment of disease management.

Introduction of diabetes passports involving both patients and professionals to improve hospital outpatient diabetes care

AIM

To investigate whether a comprehensive strategy involving both patients and professionals, with the introduction of a diabetes passport as a key component, improves diabetes care.

METHODS

The first 150 consecutive patients who visited their internist for a diabetes check up at the internal medicine outpatient departments at each of nine Dutch general hospitals were included in this 1 year clustered, randomised, controlled trial. Health care professionals attended an educational meeting about the use and dissemination of the diabetes passport which is a patient held record. They also received aggregated feedback on baseline data and personal feedback. Educational meetings were also organised for patients. Patient files were used in conjunction with questionnaires to determine adherence rates. Data were analysed using multilevel regression analysis.

RESULTS

Small but significant changes were found in mean HbA1c levels. In the intervention group, positive health changes for patients were found (-0.3%) when compared to those in the control group (+0.2%). Diastolic blood pressure improved slightly, but no changes were found in systolic blood pressure or cholesterol. Improvements were found with regard to levels of examination of patients' feet and in patient education.

CONCLUSIONS

Efforts to improve professional practice involving both professionals and patients led to small improvements in HbA1c and diastolic blood pressure levels. Further study is needed to establish whether a better structured health care delivery, operating in a more supportive environment can enhance these effects.

The Health Technology Assessment-disease management instrument reliably measured methodologic quality of health technology assessments of disease management

OBJECTIVE

Systematic reviews aim to summarize the evidence in a particular topic area, giving attention to the identified methodologic quality of published research. Because research in a specific area may be susceptible to specific biases, it is assumed that the methodologic quality of Health Technology Assessment (HTA) of disease management cannot properly be measured with the existing methodologic quality assessment instruments. The purpose of this study was to describe to what extent existing instruments are useful in assessing the methodologic quality of HTA of disease management.

STUDY DESIGN AND SETTING

An inventory was made of the problems that arise when assessing the methodologic quality of six HTAs of disease management with three different instruments. Based on these findings, a new instrument is proposed and validated.

RESULTS

Problems mainly concern the items related to the study design, criteria for selection and restriction of patients, baseline and outcome measures, blinding of patients and providers, and the description of (co)-interventions.

CONCLUSION

With its more specific characteristics, the HTA-DM addresses the problems mentioned. The HTA-DM is a reliable instrument for methodologic quality assessment of HTA of disease management in comparison with the other three instruments.

Newspaper articles as a tool for cardiovascular prevention programs in a developing country

The purpose of this study was to evaluate changes in knowledge and attitudes as intermediate measures of community impact of a health education campaign using newspaper articles. The intervention involved prominently placed, illustrated newspaper articles by Heartfile (heartfile.org) with nationwide urban outreach, posted regularly in the largest English newspaper in Pakistan using newspaper donated space for a period of 130 consecutive weeks. The post intervention evaluation involved a cross sectional telephone survey in a major city. In the total sample, 26.5% were readers of the newspaper and majority of them (72%) stated that they were regular readers. These 500 persons were eligible for the interview; of these, 93% remembered having seen the Heartfile articles. In this group, 87% of the respondents stated that the articles significantly supplemented their knowledge about diet, and in 5% they were the sole source of information. With respect to exercise, these articles supplemented the knowledge of 77% of the respondents and were the sole source of information for 9% whereas in the case of smoking, knowledge was supplemented in 85% and the articles were the sole source of information in 4% of the cases. Of those interviewed, 40% reported that they had made some dietary changes, 39% made some changes in their exercise habits and 8% reduced the amount of tobacco consumption as a result of reading these articles. In relation to newspaper articles, the per article production cost was US$ 169 and the articles were read regularly by an estimated 0.66 million and occasionally by 0.79 million individuals all over the country. Newspaper articles are a useful supplement to other health education activities as part of cardiovascular disease prevention programs. Lessons from the Heartfile experience in Pakistan could be useful for other similar initiatives in low resource settings.