Quality of care for patients with Type 2 diabetes mellitus--a long-term comparison of two quality improvement programmes in the Netherlands

Technology-enabled activation of skin cancer screening for hematopoietic cell transplantation survivors and their primary care providers (TEACH)

BACKGROUND

Hematopoietic cell transplantation (HCT) is a curative option for a growing number of patients with hematologic diseases and malignancies. However, HCT-related factors, such as total body irradiation used for conditioning, graft-versus-host disease, and prolonged exposure to immunosuppressive therapy, result in very high risk for melanoma and non-melanoma skin cancer (NMSC). In fact, skin cancer is the most common subsequent neoplasm in HCT survivors, tending to develop at a time when survivors' follow-up care has largely transitioned to the primary care setting. The goal of this study is to increase skin cancer screening rates among HCT survivors through patient-directed activation alone or in combination with physician-directed activation. The proposed intervention will identify facilitators of and barriers to risk-based screening in this population and help reduce the burden of cancer-related morbidity after HCT.

METHODS/DESIGN

720 HCT survivors will be enrolled in this 12-month randomized controlled trial. This study uses a comparative effectiveness design comparing (1) patient activation and education (PAE, N = 360) including text messaging and print materials to encourage and motivate skin examinations; (2) PAE plus primary care physician activation (PAE + Phys, N = 360) adding print materials for the physician on the HCT survivors' increased risk of skin cancer and importance of conducting a full-body skin exam. Patients on the PAE + Phys arm will be further randomized 1:1 to the teledermoscopy (PAE + Phys+TD) adding physician receipt of a portable dermatoscope to upload images of suspect lesions for review by the study dermatologist and an online course with descriptions of dermoscopic images for skin cancers.

DISCUSSION

When completed, this study will provide much-needed information regarding strategies to improve skin cancer detection in other high-risk (e.g. radiation-exposed) cancer survivor populations, and to facilitate screening and management of other late effects (e.g. cardiovascular, endocrine) in HCT survivors.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04358276 . Registered 24 April 2020.

Design of the PROstate cancer follow-up care in Secondary and Primary hEalth Care study (PROSPEC): a randomized controlled trial to evaluate the effectiveness of primary care-based follow-up of localized prostate cancer survivors

BACKGROUND

In its 2006 report, From cancer patient to cancer survivor: lost in transition, the U.S. Institute of Medicine raised the need for a more coordinated and comprehensive care model for cancer survivors. Given the ever increasing number of cancer survivors, in general, and prostate cancer survivors, in particular, there is a need for a more sustainable model of follow-up care. Currently, patients who have completed primary treatment for localized prostate cancer are often included in a specialist-based follow-up care program. General practitioners already play a key role in providing continuous and comprehensive health care. Studies in breast and colorectal cancer suggest that general practitioners could also consider to provide survivorship care in prostate cancer. However, empirical data are needed to determine whether follow-up care of localized prostate cancer survivors by the general practitioner is a feasible alternative.

METHODS

This multicenter, randomized, non-inferiority study will compare specialist-based (usual care) versus general practitioner-based (intervention) follow-up care of prostate cancer survivors who have completed primary treatment (prostatectomy or radiotherapy) for localized prostate cancer. Patients are being recruited from hospitals in the Netherlands, and randomly (1:1) allocated to specialist-based (N = 195) or general practitioner-based (N = 195) follow-up care. This trial will evaluate the effectiveness of primary care-based follow-up, in comparison to usual care, in terms of adherence to the prostate cancer surveillance guideline for the timing and frequency of prostate-specific antigen assessments, the time from a biochemical recurrence to retreatment decision-making, the management of treatment-related side effects, health-related quality of life, prostate cancer-related anxiety, continuity of care, and cost-effectiveness. The outcome measures will be assessed at randomization (≤6 months after treatment), and 12, 18, and 24 months after treatment.

DISCUSSION

This multicenter, prospective, randomized study will provide empirical evidence regarding the (cost-) effectiveness of specialist-based follow-up care compared to general practitioner-based follow-up care for localized prostate cancer survivors.

TRIAL REGISTRATION

Netherlands Trial Registry, Trial NL7068 (NTR7266). Prospectively registered on 11 June 2018.

Drug treatment of type 2 diabetes: Its cost is significantly associated with HbA1c levels

AIMS

To examine the relationship between costs of hyperglycaemia drug treatment and glycemic control amongst people with type 2 diabetes (T2D).

METHODS

This observational study utilised data from the QUALIDIAB database on 3,452 T2D patients seen in Diabetes Centers in Argentina. Patients were classified according to their HbA1c value into two groups: on target (OT; HbA1c ≤ 7%), and not on target (NOT; HbA1c > 7%); within each category we considered clinical and metabolic indicators, as well as type of hyperglycaemia treatment. Monthly expenditure on drugs was estimated by micro-costing. Multivariable regression analysis was used to evaluate the association between cost of hyperglycaemia treatment and HbA1c values.

RESULTS

In total, 48.9% of the participants have HbA1c OT values. Overall monthly per capita costs of this treatment increased significantly (134%) in the NOT group. Multivariable regression analysis showed that expenditure for hyperglycaemia drugs treatment was significant associated with glycemic control (OR: 0.705), diabetes duration (OR: 1.017), systolic blood pressure (OR: 1.006) and treatment of T2D (OR: 2.622).

CONCLUSIONS

HbA1c NOT significantly increases drugs monthly cost of hyperglycaemia treatment in people with T2D in a country with an emerging market economy.

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

AIM

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).

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

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

AIM

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

Baseline data demonstrated the need of implementing an intervention to improve diabetes care and treatment outcomes.

The primary care provider (PCP)-cancer specialist relationship: A systematic review and mixed-methods meta-synthesis

Although they are critical to models of coordinated care, the relationship and communication between primary care providers (PCPs) and cancer specialists throughout the cancer continuum are poorly understood. By using predefined search terms, the authors conducted a systematic review of the literature in 3 databases to examine the relationship and communication between PCPs and cancer specialists. Among 301 articles identified, 35 met all inclusion criteria and were reviewed in-depth. Findings from qualitative, quantitative, and disaggregated mixed-methods studies were integrated using meta-synthesis. Six themes were identified and incorporated into a preliminary conceptual model of the PCP-cancer specialist relationship: 1) poor and delayed communication between PCPs and cancer specialists, 2) cancer specialists' endorsement of a specialist-based model of care, 3) PCPs' belief that they play an important role in the cancer continuum, 4) PCPs' willingness to participate in the cancer continuum, 5) cancer specialists' and PCPs' uncertainty regarding the PCP's oncology knowledge/experience, and 6) discrepancies between PCPs and cancer specialists regarding roles. These data indicate a pervasive need for improved communication, delineation, and coordination of responsibilities between PCPs and cancer specialists. Future interventions aimed at these deficiencies may improve patient and physician satisfaction and cancer care coordination. CA Cancer J Clin 2017;67:156-169. © 2016 American Cancer Society.

Characteristics of Organizational Resources and Supports for Self Management in Primary Care

PURPOSE

The purpose of this article is to describe components of organizational support for self-management in primary care and provide illustrations of each of these components from the Diabetes Initiative's Advancing Diabetes Self Management (ADSM) projects.

METHODS

Elements of organizational resources and supports for diabetes self-management in primary care were developed from the experience of the ADSM projects and in collaboration with Diabetes Initiative staff and experts.

RESULTS

Eight elements of organizational support for self-management were identified: (1) the establishment of patient care teams, (2) continuity of care, (3) coordination of referrals, (4) documentation of self-management support, (5) ongoing quality improvement, (6) patient input, (7) staff training and education, and (8) integration of self-management into primary care.

CONCLUSION

Establishing a comprehensive system of care for people with diabetes is enabled by an infrastructure of organizational resources and supports for self-management in primary care settings. These components of organizational support provide guidance for integrating diabetes self-management services into primary care settings.

Long-term glycaemic control (HbA1c), not admission glucose, predicts hospital re-admission in diabetic patients

BACKGROUND

Diabetic patients are commonly hyperglycaemic on presentation. Admission hyperglycaemia is associated with adverse outcomes, particularly prolonged hospitalisation. Improving inpatient glycaemia may reduce length of hospital stay (LOS) in diabetic patients.

AIMS

To determine whether in-hospital recognition and treatment of admission hyperglycaemia in diabetic patients is associated with reduced LOS.

METHODS

Medical records were reviewed from 1 November 2011 to 31 May 2012 for 162 diabetic patients admitted with a blood glucose level (BGL) ≥11.1mmol/L. In-hospital outcomes were compared. Stepwise multiple regression was used to evaluate factors contributing to LOS.

RESULTS

Compared to the untreated individuals (n=67), hyperglycaemia treatment (n=95) was associated with a longer LOS (median eight vs. four days, p<0.01), higher HbA1c (9.0 vs. 7.3 per cent, p<0.01), more infections (50 vs. 25 per cent, p<0.01), and more patients with follow-up plans (35 vs. 10 per cent, p<0.01). Higher HbA1c was significantly related to more follow-up (ρs=0.30, n=110, p<0.01) with a trend to lower re-admission in those with follow-up plans (ρs=-1.41, n=162, p=0.07).

CONCLUSION

Recognition and treatment of admission hyperglycaemia in diabetic patients was associated with longer LOS than if untreated. Contributory factors to LOS include: illness severity, infections, and higher HbA1c. Although follow-up plans were few (27 per cent) for diabetic patients with hyperglycaemia, it was significantly more likely in those with higher HbA1c. Diabetic patients' complexities require timely multidisciplinary team involvement. Improved follow-up care, particularly for hospitalised diabetic patients identified to have chronically poor glycaemic control, may help prevent future diabetic patient re-admissions.

Prevalence of vascular complications and factors predictive of their development in young adults with type 1 diabetes: systematic literature review

Background

Vascular complications curtail life expectancy and quality of life in type 1 diabetes and development at younger ages is particularly detrimental. To date no review has summarised the prevalence or factors predicting their development in young adults.

Methods

A quantitative epidemiological systematic review was conducted to identify the prevalence and predictive factors for development of retinopathy, nephropathy and hypertension in young adults (sample age mean [plus 1SD] 18–30 years) with type 1 diabetes, using processes adapted from established review methods set out by the Centre for Reviews and Dissemination.

MEDLINE (Ovid), Scopus (Elsevier), CINAHL, Science Direct (Elsevier), Google Scholar and Cochrane databases were searched to identify relevant articles published between 1993 and June 2014. From this eleven papers were retrieved, appraised and results summarised by three reviewers using established methods.

Results

Some form of retinopathy occurred in up to almost half of participants; more severe forms affected up to one in ten. One in six was reported with microalbuminuria; one in 14 had macroalbuminuria. Hypertension occurred in almost one in two participants. Applying out-dated high thresholds this decreased to approximately one in ten participants. Glycaemic control was a consistent predictor of vascular disease in this age group.

Conclusion

Prevalence rates of retinopathy, nephropathy and hypertension in young adults with type 1 diabetes emphasise the importance of regular complication screening for early detection and treatment. The predictive effect of glycaemic control reinforces its importance for prevention of vascular complications.

Electronic supplementary material

The online version of this article (doi:10.1186/1756-0500-7-593) contains supplementary material, which is available to authorized users.

Risk-based health care, the cancer survivor, the oncologist, and the primary care physician

Cancer survivors face substantial risks for morbidity, reduced quality of life, and premature mortality related to the cancer itself and/or the interventions undertaken to control cancer. Risk-based care that involves a personalized systematic plan of periodic screening, surveillance, and prevention relevant to the cancer experience is recommended to address the comprehensive health needs of the growing population of cancer survivors. Risk-based care and coordination between oncology and primary care providers have been identified as important metrics of quality cancer survivorship care. Various models of survivorship care, treatment summaries, and survivorship care plans have been promoted as methods to facilitate communication among providers across care transitions and improve survivor access to quality survivorship care. However, research supporting the feasibility of implementing these practices and their effectiveness in enhancing health outcomes is limited. This article reviews key concepts underpinning clinical and research initiatives endeavoring to improve access to quality care among long-term survivors and summarizes results of intervention studies implementing these elements in transitioning survivors from oncology to primary care providers for long-term follow-up care.

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

AIMS

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Clinical, metabolic and psychological outcomes and treatment costs of a prospective randomized trial based on different educational strategies to improve diabetes care (PRODIACOR)

AIM

To evaluate the effect of system interventions (formalized data collection and 100% coverage of medications and supplies) combined with physician and/or patient education on therapeutic indicators and costs in Type 2 diabetes.

METHODS

This was a randomized 2 × 2 design in public health, social security or private prepaid primary care clinics in Corrientes, Argentina. Thirty-six general practitioners and 468 adults with Type 2 diabetes participated. Patients of nine participating physicians were selected randomly and assigned to one of four structured group education programmes (117 patients each): control (group 1), physician education (group 2), patient education (group 3), and both physician education and patient education (group 4), with identical system interventions in all four groups. Outcome measures included HbA(1c), BMI, blood pressure, fasting glucose, lipid profile, drug consumption, resource use and patient well-being at baseline and every 6 months up to 42 months.

RESULTS

HbA(1c) decreased significantly from 4 mmol/mol to 10 mmol/mol by 42 months (P < 0.05); the largest and more consistent decrease was in the groups where patients and physicians were educated. Blood pressure and triglycerides decreased significantly in all groups; the largest changes were recorded in the combined education group. The World Health Organization-5 Lowe score showed significant improvements, without differences among groups. The lowest treatment cost was seen in the combined education group.

CONCLUSIONS

In a primary care setting, educational interventions combined with comprehensive care coverage resulted in long-term improvement in clinical, metabolic and psychological outcomes at the best cost-effectiveness ratio.

Effect of an educational intervention in primary care physicians on the compliance of indicators of good clinical practice in the treatment of type 2 diabetes mellitus [OBTEDIGA project]

AIM

To evaluate the effect of an educational intervention among primary care physicians on several indicators of good clinical practice in diabetes care.

METHODS

Two groups of physicians were randomly assigned to the intervention or control group (IG and CG). Every physician randomly selected two samples of patients from all type 2 diabetic patients aged 40 years and above and diagnosed more than a year ago. Baseline and final information were collected cross-sectionally 12 months apart, in two independent samples of 30 patients per physician. The educational intervention comprised: distribution of educational materials and physicians' specific bench-marking information, an on-line course and three on-site educational workshops on diabetes. External observers collected information directly from the physicians and from the medical records of the patients on personal and family history of disease and on the evolution and treatment of their disease. Baseline information was collected retrospectively in the control group.

RESULTS

Intervention group comprised 53 physicians who included a total of 3018 patients in the baseline and final evaluations. CG comprised 50 physicians who included 2868 patients in the same evaluations. Measurement of micro-albuminuria in the last 12 months (OR = 1.6, 95% CI: 1.1-2.4) and foot examination in the last year (OR = 2.0, 95% CI: 1.1-3.6) were the indicators for which greater improvement was found in the IG. No other indicator considered showed statistically significant improvement between groups.

CONCLUSIONS

The identification of indicators with very low level of compliance and the implementation of a simple intervention in physicians to correct them is effective in improving the quality of care of diabetic patients.

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

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Type 2 diabetes patients educated by other patients perform at least as well as patients trained by professionals

BACKGROUND

Diabetes education can improve the quality of care of people with diabetes, but many organizations are not equipped to manage its implementation. Involving people with diabetes in the education process can overcome the problem. Thus, we compared clinical, metabolic and psychological outcomes in people with type 2 diabetes 1 year after attending a structured diabetes education programme implemented by professional educators versus the same programme implemented by trained peers with diabetes that also provided ongoing peer support.

METHODS

People with type 2 diabetes (25-75 years) were randomly assigned to attend a 4-week structured diabetes education course delivered by professional educators (control) or previously trained peers (peer). Peers also received continuing psychological support, including examples on how to apply diabetes knowledge in daily life via weekly peer cellular phone calls and bimonthly face-to-face interviews in small groups (ten patients), using a structured questionnaire related to the patient's clinical, metabolic and psychological progress. Identical outcome data from both groups were used for follow-up.

RESULTS

Both groups had a comparable positive effect on clinical, metabolic and psychological indicators immediately following the programme. Over the following year, peer-educated subjects had lower A(1C) and systolic blood pressure and showed higher adherence to physical activity and better control of hypoglycaemic episodes.

CONCLUSION

The non-inferiority of the peer outcomes and the mentioned improvements in this group suggest that volunteer trained peer educators and ongoing support can be successful. This approach provides an effective alternative method of education, especially in areas with limited availability of professionals and economic resources.

Cardiovascular screening in general practice in a low SES area

Background

Lower social economic status (SES) is related to an elevated cardiovascular (CV) risk. A pro-active primary prevention CV screening approach in general practice (GP) might be effective in a region with a low mean SES. This approach, supported by a regional GP laboratory, was investigated on feasibility, attendance rate and proportion of persons identified with an elevated risk.

Methods

In a region with a low mean SES, men and women aged ≥50/55 years, respectively, were invited for cardiovascular risk profiling, based on SCORE 10-year risk of fatal cardiovascular disease and additional risk factors (family history, weight and end organ damage). Screening was performed by laboratory personnel, at the GP practice. Treatment advice was based on Dutch GP guidelines for cardiovascular risk management. Response rates were compared to those in five other practices, using the same screening method.

Results

521 persons received invitations, 354 (68%) were interested, 33 did not attend and 43 were not further analysed because of already known diabetes/cardiovascular disease. Eventually 278 risk profiles were analysed, of which 60% had a low cardiovascular risk (SCORE-risk <5%). From the 40% participants with a SCORE-risk ≥5%, 60% did not receive medication yet for hypertension/hypercholesterolemia. In the other five GPs response rates were comparable to the currently described GP.

Conclusion

Screening in GP in a low SES area, performed by a laboratory service, was feasible, resulted in high attendance, and identification and treatment advice of many new persons at risk for cardiovascular disease.

Room for improvement in diabetes care among First Nations in northern Quebec (Eeyou Istchee): reasonable management of glucose but poor management of complications

OBJECTIVES

To evaluate the clinical management of type 2 diabetes in the Eeyou Istchee communities of northern Quebec.

STUDY DESIGN

Retrospective quality assurance audit.

METHODS

Patients with diabetes were identified using the Cree Diabetes Information System. Charts of eligible patients were audited for healthcare visits, glycemic control, blood pressure, lipid profile, pharmacological treatment and complications for the 2006 calendar year. Analyses were performed to assess the association of disease duration, age, target glycemic and blood pressure control with diabetes complications.

RESULTS

Half of the patients (49.7%) achieved target HbA1c, 53.6% had a blood pressure of ≤130/80 and 58.7% had an LDL of ≤2.5 mmol/L. The proportion of patients meeting all 3 targets was low at 17.1%. The mean number of diabetes-related clinic visits was high, with an average of 3.9 visits to a physician and an average of 8.7 visits to a registered nurse. Of patients with a documented diabetic complication, 39.4% of patients were not being managed with an ACE/ARB and 48.2% of patients were not prescribed a statin.

CONCLUSIONS

These findings suggest a possible treatment gap for risk factors and complications management. To circumvent further increases in diabetes-related complications, emphasis should be placed on improved healthcare worker training, greater use of clinical management and patient education tools and improved communication during the diabetes-related clinical visits. Development of a culturally appropriate multidisciplinary approach towards improved understanding of diabetes and multifactorial risk management for diabetic patients is essential for the prevention of diabetic complications.

Trends in chronic complications of type 2 diabetic patients from Spanish primary health care centres (GEDAPS study): ten year-implementation of St. Vincent recommendations

AIMS

To assess the implementation of St. Vincent recommendations in Catalonia (Spain) between 1993 and 2003 following a program of Continuous Quality Improvement.

METHODS

65 health centres (433 health professionals) took part in the study. From 1993 to 2003, 34 workshops on consensus guidelines and feedback referring to the variables that needed to be improved were carried out. Data collection was obtained concerning, socio-demographic information, and disease characteristics and complications from patients with type 2 diabetes mellitus (DM).

RESULTS

Most cardiovascular risk factors improved: glycosilated haemoglobin (HbA1c) was reduced by 0.7% (95% CI: -0.49:-0.90); total cholesterol by 0.54mmol/L (95% CI: -0.53:-0.55); non-high density lipoprotein cholesterol by 0.81mmol/L (95% CI: -0.80:-0.82); systolic blood pressure (SBP) by 6.02mmHg (95% CI: -5.79:-6.25), and diastolic blood pressure (DBP) by 2.65mmHg (95% CI: -2.4:-2.9), with the exception of smoking and obesity, which increased by 2.1% and 5.9%, respectively. Retinopathy and albuminuria decreased by 40.7% and 46% (p<0.001), respectively. The incidence of diabetic foot lesions and amputations decreased by 65.7% and 61.1% (p<0.001), respectively. The prevalence of macrovascular complications showed a slight reduction (p=0.037). Ischemic cardiomyopathy and cerebrovascular accidents decreased by 7.7% and 17.6%, respectively.

CONCLUSIONS

Our Continuous Quality Improvement program based on St. Vincent recommendations, had a positive impact on cardiovascular risk factors. We observed a reduction of chronic complications in type 2 DM patients.

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

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: 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.

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.

The primary care nurse practitioner and cancer survivorship care

PURPOSE

To examine the important role that primary care nurse practitioners (NPs) have in providing long-term surveillance and health maintenance for breast, prostate, and colorectal cancer survivors throughout the continuum of cancer care.

DATA SOURCES

MEDLINE, CINAHL, MD-Consult, and Cochrane's databases were utilized with the inclusion of primary research and critical research reviews from January 1995 through March 2008. Select organizational websites were also cited.

CONCLUSIONS

Cancer patients experience changes in the focus of their care when management shifts from the treatment of cancer to management of treatment side effects and outcomes, to survivorship care, and to secondary cancer treatment. NPs have a strong impact on cancer survivorship care by serving in various roles and settings throughout the cancer trajectory to improve patient outcomes.

IMPLICATIONS FOR PRACTICE

Cancer survivorship care expands beyond specialty settings, into primary care. NPs have a key role in ensuring continuity of care for patients with cancer. Models of care that promote continuity and high quality of care for patients with cancer include the shared-care and nurse-managed health center models. The formal collaborative plan of care is essential in long-term cancer survivorship care.

Adherence to evidence-based guidelines for depression and anxiety disorders is associated with recording of the diagnosis

OBJECTIVES

To assess professionals' adherence to evidence-based guidelines and to investigate whether or not this is influenced by recording of the diagnosis and symptom severity.

METHOD

Analysis of baseline cross-sectional data of a cohort study of 721 primary care patients with a confirmed diagnosis of a depressive or anxiety disorder. Information on the management of depressive and anxiety disorders was gathered from the electronic medical patient records. Guideline adherence was measured by an algorithm, based on performance indicators.

RESULTS

Forty-two percent of the patients with a depressive disorder was treated in accordance with the guideline, whereas 27% of the patients with an anxiety disorder received guideline-consistent care. The provision of care in line with current depression and anxiety guidelines was around 50% for persons with both types of disorders. Documentation of an International Classification of Primary Care diagnosis of depression or anxiety disorder appeared to have a strong influence on guideline adherence. Symptom severity, however, did not influence guideline adherence.

CONCLUSIONS

Adherence to depression and anxiety guidelines can be improved, even when the general practitioner makes the diagnosis and records it. Data on actual health care delivery and quality of care provide insight and may be useful in developing quality improvement activities.

Prevalence of cardiovascular disease and risk factors in a type 2 diabetic population of the North Catalonia diabetes study

PURPOSE

The purpose of the study was to evaluate the prevalence of cardiovascular disease (CVD), cardiovascular risk factors (CVRFs), and their control in patients with type 2 diabetes mellitus (T2DM) at primary care settings from the North Catalonia Diabetes Study (NCDS).

DATA SOURCES

In this multicentre cross-sectional descriptive study, data were collected from a random sample of 307 patients with T2DM. The prevalence of CVD, CVRF, metabolic syndrome (MS), coronary heart disease (CHD) risk at 10 years (Framingham Point Scores), and CVRF control was evaluated. MS and lipid profiles were established according to Adult Treatment Panel III criteria.

CONCLUSIONS

CVD prevalence was 22.0% (CHD: 18.9% and peripheral ischemia: 4.5%) and more frequent in men. The prevalence of selected CVRF was: hypertension: 74.5%; dyslipidemia: 77.7%; smoking: 14.9%; obesity 44.9%, and familial CVD: 38.4%. Three or more CVRFs, including T2DM, were observed in 91.3%. MS prevalence was 68.7%. Framingham score was 10.0%, higher in men than in women. CVD prevalence was related to: age, number of CVRFs, duration of diabetes, familial history of CVD, waist circumference, hypertension, lipid profile, kidney disease, and Framingham score, but not to MS by itself. Correct lipid profiles and blood pressure were only observed in 18.9% and 24.0%, respectively, whereas platelet aggregation inhibitors were only recorded in 16.1% of the patient cohort. MS presence was not an independent risk factor of CVD in our study.

IMPLICATIONS FOR PRACTICE

The high prevalence of CVD and an inadequate control of CVRF, which were apparent in the NCDS population, would suggest that advanced practice nurses should consider incorporating specific cardiovascular assessment in their routine care of persons with T2DM.

Survivorship care: models and programs

OBJECTIVES

To review models of care for adult cancer survivors and the challenges in program development.

DATA SOURCES

Review of the literature.

CONCLUSION

As the number of cancer survivors continues to grow, so does the need to develop unique evidence-based programs and services for this population. Survivorship should become a distinct phase of care and include: surveillance for recurrence, evaluation of and treatment for medical and psychosocial consequences of treatment, recommendations for screening for new primary cancers, health promotion recommendations, and provision of a written care plan to the patient and other health professionals.

IMPLICATIONS FOR NURSING PRACTICE

Many challenges remain to evaluating care models and actualizing clinical services nationally, but oncology nurses are uniquely positioned to take the lead in the care of cancer survivors of all ages.

A comparison of diabetes clinics with different emphasis on routine care, complications assessment and shared care

OBJECTIVE

To compare clinical outcomes of patients attending diabetes clinics with different models of care.

METHODS

Diabetes centres which participated in the Australian National Diabetes Information Audit and Benchmarking (ANDIAB) data collection were invited to nominate whether they provided (i) routine diabetes care only (model A), (ii) routine care and structured annual complications screening (model B) or (iii) annual review and complications screening in a system of shared care with general practitioners (model C). De-identified case data were extracted from ANDIAB and outcomes according to the three clinic models were compared.

RESULTS

Data on 3052 patients from 18 diabetes centres were analysed. Centres which practised annual complications screening (models B and C) had higher rates of nephropathy and lipid screening and a higher rate of attainment of recommended blood pressure and glycated haemoglobin (HbA(1c)) targets. The implementation of appropriate treatment for patients who had not attained the targets was similar for all three clinic models.

CONCLUSIONS

In our study, clinic models which incorporate a system of structured complications screening were more likely to have met screening guidelines. Patients in a shared-care model were at least as likely to have met management targets as those attending diabetes clinics for their routine care. Therefore, a system of shared care by general practitioners supported by annual review at a diabetes clinic may be an acceptable model which improves the capacity to manage large numbers of people with diabetes, without loss of quality of care.

Point of care testing to improve glycemic control

PURPOSE

The purpose of this paper is to pilot-test the feasibility and impact of protocol-driven point-of-care HbAlc testing on levels of glycemic control and on rates of diabetic regimen intensification in an urban community health center serving low-income patients.

DESIGN/METHODOLOGY/APPROACH

The paper suggests a primary care process re-design, using point of care finger-stick HbA1c testing under a standing order protocol that provided test results to the provider at patient visit.

FINDINGS

The paper finds that the protocol was well received by both nurses and physicians. HbA1c testing rates increased from 73.6 percent to 86.8 percent (p = 0.40, n = 106). For the 69 patients who had both pre- and post-intervention results, HbAlc levels decreased significantly from 8.55 to 7.84 (p = 0.004, n = 69). At baseline, the health center as a system was relatively ineffective in responding to elevated HbA1c levels. An opportunity to intensify, i.e. a face-to-face visit with lab results available, occurred for only 68.6 percent of elevated HbAlc levels before the intervention, vs. 100 percent post-intervention (p < 0.001). Only 28.6 percent of patients with HbAlc levels >8.0 had their regimens intensified in the pre-intervention phase, compared with 53.8 percent in the post-intervention phase (p = 0.03).

RESEARCH LIMITATIONS/IMPLICATIONS

This was a pilot-study in one urban health center. Larger group-randomized controlled trials are needed.

PRACTICAL IMPLICATIONS

The health center's performance as a system, improved significantly as a way of intensifying diabetic regimens thereby achieving improved glycemic control.

ORIGINALITY/VALUE

This intervention is feasible, replicable and scalable and does not rely on changing physician behaviors to improve primary care diabetic outcomes.

Shared care by paediatric oncologists and family doctors for long-term follow-up of adult childhood cancer survivors: a pilot study

BACKGROUND

Since 75% of children with cancer will become long-term survivors, late effects of treatment are an ever increasing issue for patients. Paediatric oncologists generally agree that cancer survivors should be followed up for the remainder of their lives, but they might not be the most suitable health-care providers to follow up survivors into late adulthood. We designed a 3-year study to assess whether shared-care by paediatric oncologists and family doctors in the long-term follow-up of survivors of childhood cancers is feasible, whether a shared-care model is compatible with collection of data needed for registration of late effects, and how a shared-care model is assessed by survivors and family doctors.

METHODS

In 2004 and 2005, adult survivors of childhood cancers were randomly chosen from eligible patients diagnosed with childhood cancer (excluding CNS tumours) or Langerhans-cell histiocytosis between January, 1968, and December, 1997, and recalled to the long-term follow-up (LTFU) clinic at the University Medical Centre Groningen, Groningen, Netherlands, where they underwent physical and clinical assessments by an on-site family doctor (visit 1). At this visit, assessments were done according to guidelines of the UK Children's Cancer Study Group Late Effects Group, and late effects were graded by use of Common Terminology Criteria for Adverse Events (version 3). Follow-up assessments were done 1 year later in 2005 and 2006 by local family doctors (visit 2), who were asked to return data to the LTFU clinic. At this visit, the local family doctors were asked to complete a three-item questionnaire and patients were asked to complete a seven-item questionnaire about their satisfaction with the shared-care model. At the next consultation, which was planned for the end of the study (visit 3), the on-site family doctor advised patients about future follow-up on the basis of their individual risk of late effects. Main endpoints were numbers of participants, satisfaction ratings, and proportions of local family doctors who returned data that they obtained at visit 2 to the LTFU clinic.

FINDINGS

133 individuals were chosen at random from 210 enrolled adult survivors. 123 of 133 (92%) randomly selected survivors and 115 of 117 (98%) of their family doctors agreed to participate in the share-care programme. 103 of 115 (90%) family doctors returned data to the LTFU clinic at visit 2. 89 of 101 (88%) of survivors were satisfied with this shared-care model, as were 94 of 115 (82%) family doctors; 18 of 115 (16%) family doctors had no views either way; and three of 115 (3%) family doctors were dissatisfied.

INTERPRETATION

Shared-care by paediatric oncologists and family doctors is feasible for long-term follow-up of adult survivors of childhood cancers.

Cancer survivorship: challenges and changing paradigms

PURPOSE

We summarize the potential issues faced by cancer survivors, define a conceptual framework for cancer survivorship, describe challenges associated with improving the quality of survivorship care and outline proposed survivorship programs that may be implemented going forward.

MATERIALS AND METHODS

We performed a nonsystematic review of current cancer survivorship literature. Given the comprehensive scope and high profile, the recent report by the Institute of Medicine, From Cancer Patient to Cancer Survivor: Lost in Transition, served as the principal guide for the review.

RESULTS

In recognition of the increasing number of cancer survivors in the United States survivorship has become an important health care concern. The recent report by the Institute of Medicine comprehensively outlined deficits in the care provided to cancer survivors, and proposed mechanisms to improve the coordination and quality of followup care for this increasing number of Americans. Measures to achieve these objectives include improving communication between health care providers through a survivorship care plan, providing evidence based surveillance guidelines and assessing different models of survivorship care. Implementing coordinated survivorship care broadly will require additional health care resources, and commitment from health care providers and payers. Research demonstrating the effectiveness of survivorship care will be important on this front.

CONCLUSIONS

Potential shortcomings in the recognition and management of ongoing issues faced by cancer survivors may impact the overall quality of long-term care in this increasing population. Although programs to address these issues have been proposed, there is substantial work to be done in this area.

Reducing risks in diabetes self-management: a systematic review of the literature

OBJECTIVE

The purpose of this systematic review was to review published literature on risk-reducing interventions as part of diabetes self-management.

DATA SOURCES

Medline (1990-2007), CINAHL (1990-2007), and Cochrane Central Register of Controlled Trials (first quarter 2007) databases were searched. Reference lists from included studies were reviewed to identify additional studies.

STUDY SELECTION

Intervention studies that addressed reducing risks to help prevent or minimize diabetes complications were included.

DATA EXTRACTION

Study design, sample characteristics, interventions, and outcomes were extracted.

DATA SYNTHESIS

Thirty-three studies, represented by 39 articles, met the criteria for inclusion and were classified as smoking cessation (n = 3), eye examination (n = 2), foot care (n = 10), oral health (n = 2), vaccination (n = 1), cardiovascular risk reduction (n = 9), and comprehensive risk reduction (n = 6). Only 46.3% of the 283 outcomes measured in the 33 studies were significantly improved.

CONCLUSIONS

Reducing risks involves implementing effective risk reduction behaviors to prevent or slow the progression of diabetes complications. Recognizing risk factors for complications and what constitutes optimal preventive care is an important part of managing diabetes. Intervention studies are lacking in some areas of reducing risks. Further studies are needed to test specific interventions to reduce the risks of diabetes complications.

The willingness of general practitioners to be involved in the follow-up of adult survivors of childhood cancer

BACKGROUND

Long-term follow-up of childhood cancer survivors is mainly organised by paediatric oncologists and until now general practitioners (GPs) are rarely involved. To ensure appropriate follow-up for all survivors into adulthood, a combined effort of paediatric oncologists and general practitioners might be the solution. We investigated the willingness of GPs, who had followed a postgraduate course on late effects of cancer treatment, to participate in a shared care model for follow-up of adult childhood cancer survivors as well as what their requirements would be in case of participation.

METHODS

From the Northern Netherlands, 358 GPs participated in a postgraduate course on late effects in paediatric cancer survivors. After the course, they were asked to complete a 10-item questionnaire on motivation to participate in the regular follow-up of adult childhood cancer survivors as well as their conditions to participate.

RESULTS

The response rate was 65%. Of the responders, 97% were willing to participate in a shared care model for follow-up and 64% felt that it was their responsibility to be in charge of childhood cancer survivors. The main requirements for participation were the availability of guidelines (64%), sufficient information about the patient's medical history (37%), and short communication lines (45%). The main barriers to participate were workload (16%), lack of knowledge (15%), and lack of communication (13%).

CONCLUSION

A significant number of GPs are ready to participate in the long-term follow-up of adult childhood cancer survivors if adequate guidelines and medical information is provided and communication lines are clear.

PRODIACOR: A patient-centered treatment program for type 2 diabetes and associated cardiovascular risk factors in the city of Corrientes, Argentina

OBJECTIVE

To implement a controlled clinical trial (PRODIACOR) in a primary care setting designed 1) to improve type 2 diabetes care and 2) to collect cost data in order to be able to measure cost-effectiveness of three system interventions (checkbook of indicated procedures, patient/provider feedback and complete coverage of medications and supplies) and physician and/or patient education to improve psychological, clinical, metabolic and therapeutic indicators. All three Argentinean health subsectors (public health, social security and the private, prepaid system) are participants in the study. Patients of participating physicians were randomly selected and assigned to one of four groups: control, provider education, patient education, and provider/patient education; the system interventions were provided to all four groups.

BASELINE RESULTS

Mean BMI was 29.8 kg/m(2); most subjects had blood pressure, fasting glucose and total cholesterol above targets recommended by international standards. Only 1% had had microalbuminuria measured, 57% performed glucose self-monitoring, 37% had had an eye examination and 31% a foot examination in the preceding year. Ten percent, 26% and 73% of people with hyperglycemia, hypertension and dyslipidemia, respectively, were not on medications. Most patients treated with either insulin or oral antidiabetic agents were on monotherapy as were those treated for hypertension and dyslipidemia. WHO-5 questionnaire scores indicated that 13% of the subjects needed psychological intervention.

CONCLUSIONS

Baseline data show multiple deficiencies in the process and outcomes of care that could be targeted and improved by PRODIACOR intervention.

Results of the pilot study of DIADEM: a comprehensive disease management programme for type 2 diabetes

AIMS

The purpose of the study was to evaluate the feasibility and preliminary clinical effects of the DIADEM disease management programme for type 2 diabetic patients.

METHODS

The study was performed at two test sites (Cardiff, UK: Aachen, Germany) including 137 and 166 patients, respectively. In 16 study centres any patients with type 2 diabetes capable of communicating by phone and able to perform blood pressure, blood glucose or urine glucose self-measurements were included. The maximum programme duration was 6 months at Cardiff and 4 months at Aachen, during which patients were assessed for glycaemic control, cardiovascular risk profile and the presence of complications of diabetes. Data were entered via the internet to a central server.

RESULTS

At entry into the programme the patient group in Cardiff had significantly lower mean age (60.3+/-9.4 years versus 64.9+/-8.7 years, p<0.001) and duration of diabetes (6.1+/-5.7 years versus 7.4+/-7.0 years, p<0.05) than in Aachen, however body mass index (31.6+/-5.2 kg/m(2) versus 29.5+/-4.9 kg/m(2), p<0.01), HbA1c (7.7+/-1.2% versus 7.1+/-1.2%, p<0.001) and systolic blood pressure (138.4+/-15.1 mmHg versus 133.5+/-11.5 mmHg, p<0.001) were significantly higher. In contrast, total cholesterol (4.7+/-1.0 mmol/l versus 5.5+/-1.1 mmol/l, p<0.001) was significantly lower in Cardiff compared to Aachen. Following entry into the programme highly significant improvements in HbA1c (Cardiff from 7.7% to 7.1%, p<0.001; Aachen from 7.2% to 6.8%, p<0.05) and total cholesterol concentrations (Cardiff: 4.66-4.46 mmol/l; Aachen: 5.33-5.15 mmol/l; both p<0.05) were observed. There were no significant changes in blood pressure at either site.

CONCLUSIONS

Intensive diabetes care was delivered to DIADEM patients and relevant and significant improvements in diabetes care were achieved demonstrating that an IT-based diabetes disease management service can improve care for patients with type 2 diabetes.

Models for delivering survivorship care

Survivors of adult cancer face lifetime health risks that are dependent on their cancer, cancer treatment exposures, comorbid health conditions, genetic predispositions, and lifestyle behaviors. Content, intensity, and frequency of health care that addresses these risks vary from survivor to survivor. The aims of this article are to provide a rationale for survivor health care and to articulate a taxonomy of models of survivor care that is applicable to both community practices and academic institutions.

Sharing specialist skills for diabetes in an inner city: a comparison of two primary care organisations over 4 years

OBJECTIVE

To evaluate the effects of organizational change and sharing of specialist skills and information technology for diabetes in two primary care groups (PCGs) over 4 years.

METHODS

In PCG-A, an intervention comprised dedicated specialist sessions in primary care, clinical guidelines, educational meetings for professionals and a shared diabetes electronic patient record (EPR). Comparison was made with the neighbouring PCG-B as control. In intervention and control PCGs, practice development work was undertaken for a new contract for family doctors. Data were collected for clinical measures, practice organizational characteristics and professional and patient views.

RESULTS

Data were analysed for 26 general practices including 17 in PCG-A and nine in PCG-B. The median practice-specific proportions of patients with HbA1c recorded annually increased in both areas: PCG-A from median 65% to 77%, while PCG-B from 53% to 84%. For cholesterol recording, PCG-A increased from 50% to 76%, and PCG-B from 56% to 80%. Organizational changes in both PCGs included the establishment of recall systems, dedicated clinics and educational sessions for patients. In both PCGs, practices performing poorly at baseline showed the greatest improvements in organization and clinical practice. Primary care professionals' satisfaction with access and communication with diabetes specialist doctors and nurses increased, more so in the intervention PCG. Only 16% of primary care professional respondents used the diabetes EPR at least monthly. Patient satisfaction and knowledge did not change.

CONCLUSIONS

Improvements in practices' organizational arrangements were associated with improvements in clinical care in both PCGs. Sharing specialist skills in one PCG was associated with increased professional satisfaction but no net improvement in clinical measures. A shared diabetes EPR is unlikely to be used, unless integrated with practice information systems.

"Glucometrics"--assessing the quality of inpatient glucose management

BACKGROUND

For patients with diabetes, the quality of outpatient glycemic control is readily assessed by hemoglobin A1c. In contrast, standardized measures for assessing the quality of blood glucose (BG) management in hospitalized patients are lacking. Because of recent studies demonstrating the benefits of strict glycemic control in critically ill patients, hospitals nationwide are dedicating resources to address this important issue. To facilitate advances in this nascent field, standardized metrics for inpatient glycemic control should be developed and validated.

METHODS

We used 1 month of fingerstick BG levels from a general hospital ward to develop and test three analytic models, based on three units of inpatient BG analysis: population (i.e., ward), patient-day, and patient. To assess the effect of the source of blood samples, we repeated these analyses after adding venous plasma glucose levels. Finally, we employed an idealized intensive care unit data set to establish "gold standard" metrics for inpatient glycemic control.

RESULTS

Mean and median BG levels and the proportion of BG levels within an "optimal" range (80-139 mg/dL) were similar among the three models, whereas hypoglycemic and hyperglycemic event rates varied considerably. Inclusion of venous glucose levels did not substantially affect the results. Of the three models tested, the patient-day model appears to most faithfully reflect the quality of inpatient glycemic control. Achieving 85% of BG levels within optimal range may be considered gold standard.

CONCLUSIONS

If validated elsewhere, these "glucometrics" would permit objective comparisons of inpatient glycemic control among hospitals and patient care units, and would allow institutions to gauge the success of their quality improvement initiatives.

Ecological approaches to self-management: the case of diabetes

In the Diabetes Initiative of The Robert Wood Johnson Foundation, an ecological perspective helped identify the following key resources and supports for self-management (RSSM): individualized assessment, collaborative goal setting, skills enhancement, follow-up and support, access to resources, and continuity of quality clinical care. These RSSM reflect the grounding of diabetes self-management in the context of social and environmental influences. Research supports the value of each of these key resources and supports. Differences among self-management interventions may be seen as complementary, rather than conflicting, ways of providing RSSM. This way of understanding differences among interventions may aid development of varied programs to reach diverse audiences. In contrast to the "5 A's" model of key provider services (Assess, Advise, Agree, Assist, and Arrange), RSSM articulate self-management from the perspective of individuals' needs. Both approaches emphasize identification of goals, teaching of skills, and facilitation and reinforcement of the use of those skills.