Quality of diabetes care in public primary care clinics in Hong Kong

Health Literacy, Self-Efficacy and Glycemic Control in Patients With Diabetes Type 2 in a Greek Population

Aim  To investigate the relationship between health literacy (HL), self-efficacy (SE), and achievement of treatment goals in patients with type 2 diabetes mellitus (T2DM). Method The cross-sectional study was conducted with a random sample of patients with T2DM attending the diabetology clinic and the Home Care department of the General Hospital of Drama, Greece. They completed two questionnaires: the short form of the European Health Literacy Survey Questionnaire (HLS-EU-Q16) to measure HL and the Diabetes Management Self-Efficacy Scale (DMSES) for people with T2DM to measure SE. Medical history, demographic characteristics, and values related to glycemic control were also recorded. Linear regression analysis was used to search for the dependence of glycosylated hemoglobin (A1C) values with HL and SE and the dependence between them. Result About 120 patients with T2DM (response rate of 92.3%) were enrolled in the study. The mean age of the participants was 62.5 years [standard deviation (SD) = 10.6 years] and most of them were female (53.3%). A1C was found to be significantly negatively associated with diet, physical activity, and SE score. Also, a statistically significant positive correlation was found between HL and SE. HL was correlated with age, gender, education level, and A1C, with women and older people having lower HL, while conversely higher education level was significantly associated with higher HL. Higher A1C was significantly associated with lower HL. Also, SE partially mediates the relationship between HL and A1C, in a significant way. Conclusion The results of the study confirm the important role of HL and SE in the successful management of T2DM. Multi-level educational interventions for diabetic patients could improve HL and SE and promote diabetes self-management.

Clinical outcomes and economic evaluation of patient-centered care system versus routine-service system for patients with type 2 diabetes in Thailand

Introduction

Patient-centered care in diabetes is another approach for outcome improvement, yet the supporting economic and clinical evidence remains limited in Thailand.

Objectives

This study compared health outcomes and cost-utility of implementing Patient-Centered Care Systems (PCCS) in a primary care setting vs. the Routine Service System (RSS) in a hospital setting.

Methods

The economic evaluation was performed using a randomized controlled study design. The participants aged ≥18 were enrolled from Phimai City in Nakhon Ratchasima Province, Thailand from June 2022 to February 2023. Totally, 309 well-controlled patients with initial care in a hospital were referred to receive the PCCS at the primary care setting or remained receiving the RSS in the hospital. Outcomes of different approaches such as fasting blood sugar, Hemoglobin A1c (HbA1c), direct medical costs, direct nonmedical costs and utility were prospectively collected at months 0, 3 and 6. Fisher's exact test, t-test or Wilcoxon signed-rank test were used to analyze data, whichever was appropriate. An incremental cost-effectiveness ratio was calculated, and various sensitivity analyses were performed.

Results

The PCCS showed significantly reduced HbA1c (p < 0.001) and a greater number of patients with improved HbA1c (p < 0.001). The PCCS were a cost-saving strategy due to incurring lower total costs (60.15 vs. 73.42 USD) and gaining more quality-adjusted life-years (QALY)(0.340 vs. 0.330) compared with the RSS. With a ceiling ratio of 4,659 USD/QALY, the PCCS had a 94.6 % probability of being cost-effective.

Conclusion

This finding indicated that the PCCS in a primary care setting was a cost-saving strategy by lowering cost, providing a higher quality of life and improving glycemic control compared with the RSS in a hospital setting. However, generalizing the findings in a country as a whole, the economic evaluation of PCCS and RSS should be conducted among different levels of hospitals from all regions in Thailand.

Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system

BACKGROUND

Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system.

OBJECTIVE

To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan.

METHODS

This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program.

RESULTS

T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one.

CONCLUSIONS

Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.

Trends in the process and outcome indicators of type 2 diabetes care: a cohort study from Eastern Finland, 2012-2017

Background

Evidence-based guidelines include concrete treatment targets that can be used as process and outcome indicators in the evaluation of the quality of healthcare services and diabetes care. Quality improvement can be evaluated by monitoring longitudinal trends in the care indicators on the system level. The aim of this study is to describe trends in the processes and outcomes of care among people with type 2 diabetes in North Karelia, Finland.

Methods

The data consist of all adults with type 2 diabetes (identified from the EHRs using ICD-10 codes) who used primary or specialized care services in North Karelia during 2012–2017. The diabetes care was evaluated using the measurement activity, treatment levels, and the achievement of the treatment targets for HbA1c and LDL as care indicators. Logistic and linear models with generalized estimating equations were used to assess the differences between years, sexes, and age groups.

Results

The proportion of patients with annual measurement varied between 75.8 and 78.1% for HbA1c and between 67.4 and 69.1% for LDL during a five-year follow-up. The changes in average levels were moderate: a 0.2% (2 mmol/mol) increase for HbA1c and a 0.1 mmol/l decrease for LDL. Anyway, the proportion of patients meeting the treatment target for HbA1c decreased from 72.7 to 67.3% (age-adjusted decrease: 5.7%p, 95% CI: 4.5–6.9) and for LDL it increased from 53.4 to 59.5% (age-adjusted increase: 5.6%p, 95% CI: 4.2–7.0). Women were measured and met the HbA1c target level more often compared with men. Conversely, men met the LDL target level more often than women, and the age-adjusted difference between sexes increased smoothly from 7.9%p to 11.7%p.

Conclusions

The achievements in relation to type 2 diabetes care in North Karelia are very good, but no major improvement was observed during follow-up. HbA1c levels had a rising tendency and LDL levels declining tendency indicating quality improvement in LDL management, but challenges in further improvement in glucose control.

Process, quality and challenges of diabetes care in primary care: a study of district health network in Thailand

This study aimed to describe the process of care, assess the quality of care based on defined indicators, and identify challenges associated with providing diabetes care via sub-district health promotion hospital (SHPH) facilities in Thailand. Primary care policy has directed that diabetes care be delivered via SHPH in order to reduce hospital congestion and minimize travel costs for patients. Limited data is available regarding the structure for providing care. Likewise, barriers to delivery of optimal care have not been well defined, especially from the perspective of health care providers. This study employed mixed-methods research, which included semi-structured interviews to gain insights into the current diabetes care process, a descriptive study to evaluate quality of care, and use of a focus group to identify challenges associated with delivery of diabetic care via SHPH. Diabetes care processes in primary care included multiple steps and involved collaboration between various health care providers at both the hospital and SHPH. Four process indicators and one outcome had been achieved but performance of other indicators was apparently low. Three factors were found to pose challenges to providing this service: the resources of the health service, the delivery of services, and patient factors. SHPH require additional support, particularly in the areas of primary care workforce, finance, medical device procurement, and patient information systems. While delivery of diabetes care via primary care centers has been well established in Thailand, regional differences in the quality of care persist. Additional support is required to strengthen the primary care system nationwide.

Systematic review and meta-analysis of patient race/ethnicity, socioeconomics, and quality for adult type 2 diabetes

OBJECTIVE

To review the evidence of the association between performance in eight indicators of diabetes care and a patient's race/ethnicity and socioeconomic characteristics.

DATA SOURCE

Studies of adult patients with type 2 diabetes in MEDLINE published between January 1, 2000, and December 31, 2018.

STUDY DESIGN

Systematic review and meta-analysis of regression-based studies including race/ethnicity and income or education as explanatory variables. Meta-analysis was used to quantify differences in performance associated with patient race/ethnicity or socioeconomic characteristics. The systematic review was used to identify potential mechanisms of disparities.

DATA COLLECTION

Two coauthors separately conducted abstract screening, study exclusions, data extraction, and scoring of retained studies. Estimates in retained studies were extracted and, where applicable, were standardized and converted to odds ratios and standard errors.

PRINCIPAL FINDINGS

Performance in intermediate outcomes and process measures frequently exhibited differences by race/ethnicity even after adjustment for socioeconomic, lifestyle, and health factors. Meta-analyses showed black patients had lower odds of HbA1c and blood pressure (BP) control (OR range: 0.67-0.68, P < .05) but higher odds of receiving eye or foot examination (OR range: 1.22-1.47, P < .05) relative to white patients. A high school degree or more was associated with higher odds of HbA1c control and receipt of eye examinations compared to patients without a degree. Meta-analyses of income included a handful of studies and were inconsistently associated with diabetes care performance. Differences in diabetes performance appear to be related to access-related factors such as uninsurance or lacking a usual source of care; food insecurity and trade-offs at very low incomes; and lower adherence among younger and healthier diabetes patients.

CONCLUSIONS

Patient race/ethnicity and education were associated with differences in diabetes quality measures. Depending on the approach used to rate providers, not adjusting for these patient characteristics may penalize or reward providers based on the populations they serve.

Inadequate achievement of ABC goals (HbA1c, blood pressure, LDL-C) among patients with type 2 diabetes in an Iranian population, 2012-2017

AIMS

This study was designed to evaluate the meeting of ABC goals in patients with type 2 diabetes. The ABC goals were defined as meeting the HbA1c <7%, systolic blood pressure <130 mmHg and diastolic blood pressure <80 mmHg, and LDL-C <100 mg/dL. We also determined the associated factors with meeting the ABC goals, as well as the effectiveness of statin therapy.

METHODS

We designed a cross-sectional study of 2008 type 2 diabetes patients attending the diabetes clinics of Valiasr Hospital of Imam Khomeini Hospital Complex. Meeting ABC goals and their associated factors were analyzed from the registered data.

RESULTS

At the end of the year 2014, 61.3% of patients met the HbA1c goal, which increased to 77.8% in 2017. Blood pressure of 79.5% of patients met the ADA recommendations by the end of the year 2014, reaching 86.6% in 2017. Moreover, 84.5% and 93.8% could reach the LDL-C goal in 2014 and 2017, respectively. The proportion for the patients meeting all three ABC goals were 23.2% and 42.1% in 2014 and 2017, respectively.

CONCLUSIONS

The level of achievement of ABC goals in Iran is lower than expected and it requires a lot of programming effort and follow-up. As patients are followed over the years, controlling ABC becomes much more favorable.

Sex differences in the risk of vascular disease associated with diabetes

Diabetes is a strong risk factor for vascular disease. There is compelling evidence that the relative risk of vascular disease associated with diabetes is substantially higher in women than men. The mechanisms that explain the sex difference have not been identified. However, this excess risk could be due to certain underlying biological differences between women and men. In addition to other cardiometabolic pathways, sex differences in body anthropometry and patterns of storage of adipose tissue may be of particular importance in explaining the sex differences in the relative risk of diabetes-associated vascular diseases. Besides biological factors, differences in the uptake and provision of health care could also play a role in women’s greater excess risk of diabetic vascular complications. In this review, we will discuss the current knowledge regarding sex differences in both biological factors, with a specific focus on sex differences adipose tissue, and in health care provided for the prevention, management, and treatment of diabetes and its vascular complications. While progress has been made towards understanding the underlying mechanisms of women’s higher relative risk of diabetic vascular complications, many uncertainties remain. Future research to understanding these mechanisms could contribute to more awareness of the sex-specific risk factors and could eventually lead to more personalized diabetes care. This will ensure that women are not affected by diabetes to a greater extent and will help to diminish the burden in both women and men.

Sex Differences in the Assessment of Cardiovascular Risk in Primary Health Care: A Systematic Review

OBJECTIVE

To determine whether sex differences exist in the assessment of cardiovascular disease (CVD) risk scores/risk factors in primary health care.

DESIGN/METHODS

PubMed and EMBASE were systematically searched on 31 January 2017. Clinical trials and observational studies were included if they reported on the assessment of CVD risk score, blood pressure (BP), cholesterol or smoking status in primary health care, stratified by sex. Meta-analyses were performed, using random effects models, to determine differences between sexes, separately for adjusted and unadjusted data.

RESULTS

Of 14,928 studies found in the search, 22 studies (including 4,754,782 patients) were included in the systematic review with the meta-analysis for quantitative assessment. Overall, the assessment rates of CVD risk score and risk factors were similar in women and men (CVD risk score: 30.7% vs. 35.2% [difference (95% CI): -4.5 (-5.1, -3.9)]; BP: 91.3% vs. 88.5% [2.8 (2.5, 3.0)]; cholesterol: 69.9% vs. 71.0% [-1.1 (-1.5, -0.8)]; and smoking: 85.9% vs. 86.7% [-0.8 (-1.1, -0.5)]). The pooled, adjusted likelihood of having the risk score, BP and cholesterol assessments were comparable between women and men: OR (95% CI): 0.87 (0.70, 1.07); 1.41 (0.89, 2.25); and 1.15 (0.82, 1.60), respectively. However, women were 32% less likely to be assessed for smoking (0.68 [0.47, 1.00]). There was substantial heterogeneity between studies and the risk of publication bias was moderate.

CONCLUSION

Despite the guideline recommendations, assessment of CVD risk score in primary health care was low in both sexes. Further, women were less likely to be assessed for their smoking status than men, whereas no sex discrepancies were found for BP and cholesterol assessments.

Association between sociodemographic determinants and health outcomes in individuals with type 2 diabetes in Sweden

BACKGROUND

Concurrent multifactorial treatment is needed to reduce consequent risks of diabetes, yet most studies investigating the relationship between sociodemographic factors and health outcomes have focused on only one risk factor at a time. Swedish health care is mainly tax-funded, thus providing an environment that should facilitate equal health outcomes in patients, independent of background, socioeconomic status, or health profile. This study aimed at investigating the association between several sociodemographic factors and diabetes-related health outcomes represented by HbA_1c , systolic blood pressure, low-density lipoprotein cholesterol, predicted 5-year risk of cardiovascular disease, and statin use.

METHODS

This large retrospective registry study was based on patient-level data from individuals diagnosed with type 2 diabetes during 2010 to 2011 (n = 416,228) in any of 7 Swedish regions (~65% of the Swedish population). Health equity in diabetes care analysed through multivariate regression analyses on intermediary outcomes (HbA_1c , systolic blood pressure, and low-density lipoprotein), predicted 5-year risk of cardiovascular disease and process (i.e., statin use) after 1-year follow-up, adjusting for several sociodemographic factors.

RESULTS

We observed differences in intermediary risk measures, predicted 5-year risk of cardiovascular disease, and process dependent on place of birth, sex, age, education, and social setting, despite Sweden's articulated vision of equal health care.

CONCLUSIONS

Diabetes patients' health was associated with sociodemographic prerequisites. Furthermore, in addition to demographics (age and sex) and disease history, educational level, marital status, and region of birth are important factors to consider when benchmarking health outcomes, e.g., average HbA_1c level, and evaluating the level of health equity between organizational units or between different administrative regions.

Meeting American Diabetes Association diabetes management targets: trends in Mauritius

AIMS

To examine the proportion of people with diabetes in the multi-ethnic country of Mauritius meeting American Diabetes Association targets in 2009 and 2015.

METHODS

Data from independent population-based samples of 858 and 656 adults with diagnosed diabetes in 2009 and 2015, respectively, were analysed with regard to recommended American Diabetes Association targets for HbA_1c , blood pressure and LDL cholesterol.

RESULTS

In 2015 compared with 2009, the proportion of people achieving American Diabetes Association targets for glycaemic control in Mauritius was higher in women (P≤0.01) and in those with only a primary education level (P=0.07), but not in men or people with a higher level of education. Achievement of blood pressure <140/90 mmHg was higher in 2015 compared with 2009 (60% vs 42%) in people of South Asian ethnicity (P<0.001), but not in those of African ethnicity (P=0.16). The percentages of people with LDL cholesterol <2.59 mmol/l were 42.1% and 50.4%, in 2009 and 2015, respectively (P=0.27). Better control of HbA_1c and blood pressure was observed in groups in which that control was poorest in 2009. The use of glucose-, blood pressure- and LDL cholesterol-lowering medication was higher in 2015 than in 2009.

CONCLUSIONS

In certain subgroups, namely women, those with poorer education and those of South Asian ethnicity, whose target achievement was the poorest in 2009, control of glycaemia and blood pressure was better in 2015 as compared with 2009. While these findings are encouraging, further work is required to improve outcomes.

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

AIMS

To examine the association of patient volume with quality of diabetes care in the primary care setting.

METHODS

We analyzed population-based data from Hospital Authority administrative database using a Hong Kong representative sample of 187,031 diabetic patients managed in 74 primary care general outpatient clinics between 04/2011 and 03/2012. We assessed the associations between annual clinic-based patient volume and quality of care in terms of adherence to care criteria of process (HbA1c test, renal function test, full lipid profile, urine protein analysis, diabetic retinopathy screening, and appropriate drug prescription) and clinical outcomes (HbA1c⩽7%, BP⩽130/80mmHg, LDL-C⩽2.6mmol/L) of care criteria, with and without adjustment for patient and clinic characteristics.

RESULTS

Patient volume was associated with three of seven process of care criteria; however, when compared to clinics in higher volume quartiles, those in lowest-volume quartile had more odds of HbA1c test (odds ratios (OR): 0.781, 0.655 and 0.646 for quartile from 2 to 4, respectively), renal function test (OR: 0.357, 0.367 and 0.590 for quartile from 2 to 4, respectively), and full lipid profile test (OR: 0.508, 0.612 and 0.793 for quartile from 2 to 4, respectively). There was no significant association between patient volume and the standards of achieving of HbA1c, BP and LDL-C outcome targets.

CONCLUSIONS

Disparities in volume and quality of diabetes care were observed in public primary care setting. Lower patient volumes at clinic level were associated with greater adherence to three process criteria but a volume-outcome association was not present.

The adoption of the Reference Framework for diabetes care among primary care physicians in primary care settings: A cross-sectional study

The prevalence of diabetes mellitus has been increasing both globally and locally. Primary care physicians (PCPs) are in a privileged position to provide first contact and continuing care for diabetic patients. A territory-wide Reference Framework for Diabetes Care for Adults has been released by the Hong Kong Primary Care Office in 2010, with the aim to further enhance evidence-based and high quality care for diabetes in the primary care setting through wide adoption of the Reference Framework.A valid questionnaire survey was conducted among PCPs to evaluate the levels of, and the factors associated with, their adoption of the Reference Framework.A total of 414 completed surveys were received with the response rate of 13.0%. The average adoption score was 3.29 (SD 0.51) out of 4. Approximately 70% of PCPs highly adopted the Reference Framework in their routine practice. Binary logistic regression analysis showed that the PCPs perceptions on the inclusion of sufficient local information (adjusted odds ratio [aOR] = 4.748, 95%CI 1.597-14.115, P = 0.005) and reduction of professional autonomy of PCPs (aOR = 1.859, 95%CI 1.013-3.411, P = 0.045) were more likely to influence their adoption level of the Reference Framework for diabetes care in daily practices.The overall level of guideline adoption was found to be relatively high among PCPs for adult diabetes in primary care settings. The adoption barriers identified in this study should be addressed in the continuous updating of the Reference Framework. Strategies need to be considered to enhance the guideline adoption and implementation capacity.

Association of more negative attitude towards commencing insulin with lower glycosylated hemoglobin (HbA1c) level: a survey on insulin-naïve type 2 diabetes mellitus Chinese patients

Background

Delay in commencing insulin among type 2 Diabetes Mellitus (DM) patients is common.  One of the reasons is patients' psychological insulin resistance, which is particularly prevalent in Chinese patients. This study examined the correlation between socio-demographic and clinical characteristics; and attitudes towards commencing insulin in Chinese primary care patients.

Method

A cross-sectional survey was conducted on 303 insulin-naïve Type 2 DM patients recruited from 15 primary care clinics across Hong Kong using the Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ). Subject selection criteria were patients on maximal oral anti-diabetes treatment who needed to commence insulin therapy. Linear regression was used to identify correlations between age, sex, educational level, occupation, body mass index, diabetes disease duration, laboratory test indicating disease control and biochemical markers including glycosylated hemoglobin (HbA1c) level, low density lipoprotein level and estimated glomeruli filtration rate, and presence of diabetic complications with the four sub-scales (self-image and stigmatization; factors promoting self-efficacy; fear of pain or needles; time and family support ) and the overall Ch-ASIQ score.

Results

The most prevalent negative attitude was ‘fear of needle injections’ (70.1 %). The most common positive attitude was ‘I can manage the skill of injecting insulin’ (67.5 %). The mean Ch-ASIQ score of 2.50 (S.D. = 0.38) was equal to the mid-score, which signified an overall ambivalent attitude among the study population. Women scored significantly higher in the fear of pain or needles subscale (p = 0.011) and had an overall more negative attitude towards commencing insulin (p = 0.016). Subjects with lower HbA1c levels also had a significantly lower Ch-ASIQ sum score (p = 0.048) indicating a more negative attitude towards commencing insulin.

Conclusion

In Chinese primary care patients with Type 2 DM, the need to commence insulin was associated with a number of negative emotions, which lead to a lower motivation to accept treatment. Perception of need as indicated by HbA1c level may be an important influencing factor determining a patient’s overall attitude towards starting insulin. Fortunately, in our setting, the injection technique does not appear to be a major barrier. However, needle fears are common, especially amongst women. Target interventions to acknowledge and help them to overcome their fears are essential before insulin treatment is commenced.

Prevalence, correlates, attitude and treatment seeking of erectile dysfunction among type 2 diabetic Chinese men attending primary care outpatient clinics

To investigate the prevalence, correlates, attitude and treatment seeking behavior of erectile dysfunction (ED) in type 2 diabetes mellitus (T2DM) patients in the primary care setting, a multi-center cross-sectional survey using a structured anonymous self-administered questionnaire was performed in 10 general outpatient clinics. Of the 603 subjects (91% response rate), the prevalence of ED men, as defined by the International Index of Erectile Function, was 79.1%. Most subjects had mild ED (28.9%), followed by mild-to-moderate ED (27.9%), then moderate ED (13.4%) and severe ED (9%). Nearly 55% of those with ED did not consider themselves as having ED. Less than 10% of them had ever sought medical treatment, although 76.1% of them wished to receive management from doctor(s) should they be diagnosed with ED. They considered the most important management from doctors to be clinical assessment (41.7%), followed by management of potential underlying cause (37.8%), referral to specialist (27.5%), education (23.9%), prescription of phosphodiesterase type 5 inhibitors (16.9%) and referral to counseling service (6.7%). The prevalence of ED was strongly associated with subjects who thought they had ED (odds ratio (OR) = 90.49 (20.00–409.48, P< 0.001)) and were from the older age group (OR = 1.043 (1.011–1.076, P = 0.008)). In conclusion, ED is highly prevalent among T2DM men. The majority of them wanted management from doctors should they have ED, but only a minority would actually voice out the request. Screening of ED among T2DM men using structural questionnaire allowed the diagnosis of more than half of the ED cases, which otherwise would have gone undiagnosed.

Association between education and quality of diabetes care in Switzerland

PURPOSE

Low socioeconomic status is associated with higher prevalence of diabetes, worse outcomes, and worse quality of care. We explored the relationship between education, as a measure of socioeconomic status, and quality of care in the Swiss context.

PATIENTS AND METHODS

Data were drawn from a population-based survey of 519 adults with diabetes during fall 2011 and summer 2012 in a canton of Switzerland. We assessed patients and diabetes characteristics. Eleven indicators of quality of care were considered (six of process and five of outcomes of care). After bivariate analyses, regression analyses adjusted for age, sex, and diabetic complications were performed to assess the relationship between education and quality of care.

RESULTS

Of 11 quality-of-care indicators, three were significantly associated with education: funduscopy (patients with tertiary versus primary education were more likely to get the exam: odds ratio, 1.8; 95% confidence interval [CI], 1.004-3.3) and two indicators of health-related quality of life (patients with tertiary versus primary education reported better health-related quality of life: Audit of Diabetes-Dependent Quality of Life: β=0.6 [95% CI, 0.2-0.97]; SF-12 mean physical component summary score: β=3.6 [95% CI, 0.9-6.4]).

CONCLUSION

Our results suggest the presence of educational inequalities in quality of diabetes care. These findings may help health professionals focus on individuals with increased needs to decrease health inequalities.

Inequalities in health care among patients with type 2 diabetes by individual socio-economic status (SES) and regional deprivation: a systematic literature review

Introduction

Quality of care could be influenced by individual socio-economic status (SES) and by residential area deprivation. The objective is to synthesize the current evidence regarding inequalities in health care for patients with Type 2 diabetes mellitus (Type 2 DM).

Methods

The systematic review focuses on inequalities concerning process (e.g. measurement of HbA1c, i.e. glycolised haemoglobin) and intermediate outcome indicators (e.g. HbA1c level) of Type 2 diabetes care. In total, of n = 886 publications screened, n = 21 met the inclusion criteria.

Results

A wide variety of definitions for ‘good quality diabetes care’, regional deprivation and individual SES was observed. Despite differences in research approaches, there is a trend towards worse health care for patients with low SES, concerning both process of care and intermediate outcome indicators. Patients living in deprived areas less often achieve glycaemic control targets, tend to have higher blood pressure (BP) and worse lipid profile control.

Conclusion

The available evidence clearly points to the fact that socio-economic inequalities in diabetes care do exist. Low individual SES and residential area deprivation are often associated with worse process indicators and worse intermediate outcomes, resulting in higher risks of microvascular and macrovascular complications. These inequalities exist across different health care systems. Recommendations for further research are provided.

Effects of Patient Empowerment Programme (PEP) on clinical outcomes and health service utilization in type 2 diabetes mellitus in primary care: an observational matched cohort study

Background

To evaluate the effects of a large population-based patient empowerment programme (PEP) on clinical outcomes and health service utilization rates in type 2 diabetes mellitus (T2DM) patients in the primary care setting.

Research Design and Subjects

A stratified random sample of 1,141 patients with T2DM enrolled to PEP between March and September 2010 were selected from general outpatient clinics (GOPC) across Hong Kong and compared with an equal number of T2DM patients who had not participated in the PEP (non-PEP group) matched by age, sex and HbA_1C level group.

Measures

Clinical outcomes of HbA_1c, SBP, DBP and LDL-C levels, and health service utilization rates including numbers of visits to GOPC, specialist outpatient clinics (SOPC), emergency department (ED) and inpatient admissions, were measured at baseline and at 12-month post-recruitment. The effects of PEP on clinical outcomes and health service utilization rates were assessed by the difference-in-difference estimation, using the generalized estimating equation models.

Results

Compared with non-PEP group, PEP group achieved additional improvements in clinical outcomes over the 12-month period. A significantly greater percentage of patients in the PEP group attained HbA_1C≤7% or LDL-C≤2.6 mmol/L at 12-month follow-up compared with the non-PEP group. PEP group had a mean 0.813 fewer GOPC visits in comparison with the non-PEP group.

Conclusions

PEP was effective in improving the clinical outcomes and reduced the general outpatient clinic utilization rate over a 12-month period. Empowering T2DM patients on self-management of their disease can enhance the quality of diabetes care in primary care.

Trial Registration

ClinicalTrials.gov NCT01935349

Development and validation of the Chinese Health Literacy Scale for Chronic Care

This study aims to develop and test the psychometric properties of the Chinese Health Literacy Scale for Chronic Care (CHLCC). This is a methodological study with a sample of 262 patients 65 years of age and older who had chronic illnesses. Pearson's correlation, independent sample t tests, and analyses of variance were used. The CHLCC showed a significant positive correlation with Chinese literacy levels (r = 0.80; p < .001) but was negatively correlated with age (r =-0.31; p <.001). Respondents who were male (t =4.34; p <.001) and who had reached Grade 12 or higher in school (F = 51.80; p <.001) had higher CHLCC scores than did their counterparts. Individuals with high levels of health literacy had fewer hospitalizations than did their counterparts (β =-0.31; incidence rate ratio = 0.73; p <.05). The CHLCC also displayed good internal reliability (Cronbach'sα =0.91) and good test-retest reliability (intraclass correlation coefficient = 0.77; p <.01). The CHLCC is a valid and reliable measure for assessing health literacy among Chinese patients with chronic illness. The scale could be used by practitioners before implementing health promotion and education.