Quality of diabetes care in community health centers

Applying National Diabetic Care Standards for the Management of a Hispanic Population Attending a Free Clinic

BACKGROUND

National quality measures set goals for diabetes management. Hispanic populations are higher risk for diabetes and associated complications, especially low-income communities. Research suggests free clinics provide suboptimal diabetes management. Our quality improvement project aims to improve diabetes management in the Hispanic free clinic population.

METHODS

Clínica Latina's volunteer medical students and physicians serve predominantly uninsured Spanish-speaking patients. Established diabetes patients that attended clinic during the study were included. Data was collected regarding patients' diabetes care for two months, then analyzed compared to quality metrics. We implemented paper checklists and electronic medical record (EMR) smart phrases for volunteers to utilize in managing diabetes.

RESULTS

32 patients were included in the study. At baseline, 78% had an A1C check in the past 3 months, 81% were on a statin. In the past year, 81% had a lipid panel, 19% had an eye exam, 63% had a diabetic foot exam, 53% had a urine microalbumin-creatinine screening. After interventions, 97% had an A1C check, 93% were on a statin, 91% had a lipid panel, 31% had an eye exam, 75% had a foot exam, 63% had a urine microalbumin-creatinine. Patients with an LDL < 100 increased from 62 to 66%. The mean A1C did not statistically significantly change. Volunteer smart phrase utilization increased from 37 to 59.1%.

CONCLUSION

We implemented a checklist and EMR smart phrase to optimize diabetes management in a student-run Hispanic free clinic, which improved quality metrics. Low-resource clinics serving Spanish-speaking populations may benefit from similar interventions to improve diabetic care.

Chronic overlapping pain conditions and long-term opioid treatment

OBJECTIVES

One in 5 people in the United States lives with chronic pain. Many patients with chronic pain experience a subset of specific co-occurring pain conditions that may share a common pain mechanism and that have been designated as chronic overlapping pain conditions (COPCs). Little is known about chronic opioid prescribing patterns among patients with COPCs in primary care settings, especially among socioeconomically vulnerable patients. This study aims to evaluate opioid prescribing among patients with COPCs in US community health centers and to identify individual COPCs and their combinations that are associated with long-term opioid treatment (LOT).

STUDY DESIGN

Retrospective cohort study.

METHODS

We conducted analyses of more than 1 million patients 18 years and older based on electronic health record data from 449 US community health centers across 17 states between January 1, 2009, and December 31, 2018. Logistic regression models were used to assess the relationship between COPCs and LOT.

RESULTS

Individuals with COPCs were prescribed LOT 4 times more often than individuals without a COPC (16.9% vs 4.0%). The presence of chronic low back pain, migraine headache, fibromyalgia, or irritable bowel syndrome combined with any of the other COPCs increased the odds of LOT prescribing compared with the presence of a single COPC.

CONCLUSIONS

Although LOT prescribing has declined over time, it remains relatively high among patients with certain COPCs and for those with multiple COPCs. These study findings suggest target populations for future interventions to manage chronic pain among socioeconomically vulnerable patients.

Application of Artificial Intelligence in Assessing the Self-Management Practices of Patients with Type 2 Diabetes

The use of Artificial intelligence in healthcare has evolved substantially in recent years. In medical diagnosis, Artificial intelligence algorithms are used to forecast or diagnose a variety of life-threatening illnesses, including breast cancer, diabetes, heart disease, etc. The main objective of this study is to assess self-management practices among patients with type 2 diabetes in rural areas of Pakistan using Artificial intelligence and machine learning algorithms. Of particular note is the assessment of the factors associated with poor self-management activities, such as non-adhering to medications, poor eating habits, lack of physical activities, and poor glycemic control (HbA1c %). The sample of 200 participants was purposefully recruited from the medical clinics in rural areas of Pakistan. The artificial neural network algorithm and logistic regression classification algorithms were used to assess diabetes self-management activities. The diabetes dataset was split 80:20 between training and testing; 80% (160) instances were used for training purposes and 20% (40) instances were used for testing purposes, while the algorithms' overall performance was measured using a confusion matrix. The current study found that self-management efforts and glycemic control were poor among diabetes patients in rural areas of Pakistan. The logistic regression model performance was evaluated based on the confusion matrix. The accuracy of the training set was 98%, while the test set's accuracy was 97.5%; each set had a recall rate of 79% and 75%, respectively. The output of the confusion matrix showed that only 11 out of 200 patients were correctly assessed/classified as meeting diabetes self-management targets based on the values of HbA1c < 7%. We added a wide range of neurons (32 to 128) in the hidden layers to train the artificial neural network models. The results showed that the model with three hidden layers and Adam's optimisation function achieved 98% accuracy on the validation set. This study has assessed the factors associated with poor self-management activities among patients with type 2 diabetes in rural areas of Pakistan. The use of a wide range of neurons in the hidden layers to train the artificial neural network models improved outcomes, confirming the model's effectiveness and efficiency in assessing diabetes self-management activities from the required data attributes.

Adapting in-person diabetes group visits to a virtual setting across federally qualified health centers

Diabetes group visits (GVs) have been shown to improve glycemic control, enrich patient self-care, and decrease healthcare utilization among patients with type 2 diabetes mellitus (T2DM). While telehealth has become routine, virtual GVs remain understudied, especially in federally qualified health centers (FQHCs). We conducted a 5-year cluster randomized trial with a waitlist control group to test the impact of diabetes GVs on patients' outcomes in Midwestern FQHCs. Due to COVID-19, the 6 waitlisted FQHCs adapted to virtual GVs. FQHC staff were provided training and support to implement virtual GVs. The GV intervention included 6 monthly 1-1.5-h long education sessions and appointments with a primary care provider. We measured staff perspectives and satisfaction via GV session logs, monthly webinars, and staff surveys and interviews. Adaptations for implementation of virtual GV included: additional staff training, video conferencing platform use, decreased session length and group size, and adjusting study materials, activities, and provider appointments. Sites enrolled a total of 48 adults with T2DM for virtual GVs. Most FQHCs were urban and all FQHCs predominantly had patients on public insurance. Patients attended 2.1 ± 2.2 GVs across sites on average. Thirty-four patients (71%) attended one or more virtual GVs. The average GV lasted 79.4 min. Barriers to virtual GVs included patient technology issues and access, patient recruitment and enrollment, and limited staff availability. Virtual GV facilitators included providing tablets, internet access from the clinic, and technical support. Staff reported spending on average 4.9 h/week planning and implementing GVs (SD = 5.9). On average, 6 staff from each FQHC participated in GV training and 1.2 staff reported past GV experience. All staff had worked at least 1 year at their FQHC and most reported multiple years of experience caring for patients with T2DM. Staff-perceived virtual GV benefits included: empowered patients to manage their diabetes, provided patients with social support and frequent contact with providers, improved relationships with patients, increased team collaboration, and better patient engagement and care-coordination. Future studies and health centers can incorporate these findings to implement virtual diabetes GVs and promote accessible diabetes care.

Community Health Centers' Performance in Cancer Screening and Prevention

INTRODUCTION

Little is known about what clinic-level factors differentiate community health centers that achieve high performance on cancer-preventive care metrics. This study aims to describe the longitudinal trends in the delivery of 3 cancer-preventive care metrics (cervical and colorectal cancer screenings and tobacco-cessation intervention) and define and compare community health centers with high cancer-preventive care performance with those with low cancer-preventive care performance.

METHODS

This observational study used 2012-2019 community health center data (N=933) from the Uniform Data System. High/low performance was based on Healthy People 2020 targets and sample distribution. For each cancer-preventive care metric, the percentage of community health centers that met high (≥70.5% at cervical or colorectal cancer screening or >80% tobacco-cessation intervention) and low thresholds at 1, 2, and all the 3 screenings was estimated. Multivariable generalized estimating equations logistic regression modeling was used to assess the community health center‒level factors associated with screening performance.

RESULTS

The community health centers' performance for tobacco-cessation intervention remained at ≥80%, with a small increase over time. Performance for cervical cancer screening remained unchanged with about 50% of patients screened. Colorectal cancer screening performance increased from around 30% in 2012 to 44% in 2019. Very few community health centers reached high performance (3%) in all the 3 indicators, and 13% of community health centers were high in any 2 of the outcomes in 2019. Higher patient volume, a greater proportion of Hispanic patients, fewer uninsured patients, and community health centers located in the Northeast region were associated with high performance in 2019.

CONCLUSIONS

Very few community health centers meet all Healthy People 2020 goals in cancer screenings and may struggle to achieve the 2030 goals. Very few indicators differentiated high performers from low performers.

The Value Transformation Framework: Applied to Diabetes Control in Federally Qualified Health Centers

Introduction

Diabetes and pre-diabetes impact more than 114 million Americans. Federally qualified health centers (FQHCs) provide care to some of the most high-risk and underinsured individuals throughout the US, twenty-one percent of whom report being told they have diabetes, compared to 11% of the general adult population. It is widely agreed our health care system requires a transformation to effectively address diabetes and its complications.

Objective

By applying the Value Transformation Framework (VTF) in health centers, the National Association of Community Health Centers (NACHC) aims to show improvements in diabetes control. This systematic strategy to transform the way health centers operate can lead to improvements in health outcomes, patient and staff experiences, costs, and equity (Quintuple Aim). Special attention is paid to the health centers’ infrastructure, people systems and care delivery systems.

Methods

Evidence-based diabetes interventions, the learning community model, and the VTF were used together to drive system improvements and activate proven diabetes control practices within eight health centers. Multidisciplinary teams at select health centers in Georgia and Iowa, with their partner primary care associations, participated in this NACHC-led quality improvement project.

Results

During the one-year intervention (January 2017–December 2017), the mean raw percentage of patients with HbA1c Poor Control decreased from 50.9% (range, 23.7–70.4%) in January to 27.5% (range, 13.6–37.4%) in December. This represents a relative improvement in diabetes control of 46%. The 1-year-intervention data also showed trends in the desired direction with statistically significant improvements related to the following interventions: a formal written clinical policy, standing orders, patient recall/outreach, performance data shared at the provider/team-level, and performance data shared at the site/organization level.

Conclusion

A conceptual model focused on transforming health center systems, organized by the NACHC Value Transformation Framework and supported by a strong learning community, can lead to better diabetes control outcomes among patients seen at health centers.

Healthcare Professionals' Perspectives of Patients' Experiences of the Self-Management of Type 2 Diabetes in the Rural Areas of Pakistan: A Qualitative Analysis

The main objective of this research work was to explore the healthcare professionals’ perspectives of type 2 diabetes patients’ experiences of self-management of diabetes in the rural area of Pakistan. In this study, we have carried out a methodological approach to use a self-management framework to direct the interview guide for healthcare professionals to examine their perceptions and expectations of their diabetes patients’ adherence to the medications prescribed. Twenty healthcare professionals were recruited in this study consisting of ten general practitioners and ten nurses from various clinics (medical centres) of Al-Rehman Hospital at Abbottabad, Pakistan. This qualitative study explored the feelings and opinions of general practitioners on patients’ compliance and adherence by using the semi-structured interview guide using a methodological framework. All interviews of participants were audiotaped and transcribed for content analysis. Six major themes were identified: patient–doctor relationship; patient’s non-adherence to diet and exercise; conflicts with the patients; low self-efficacy and feeling of “resignation with poor care”; the influence of culture on patients’ self-management activities and lack of support for patients by health care providers, patients, and their families. We have derived relevant solutions from qualitative studies and considered that communication, tailored, and shared care is the best approach for patient adherence to treatment. GPs felt that a structured consultation and follow-up in a multidisciplinary team might help to increase adherence. The results of this qualitative health research highlighted the challenges healthcare professionals are facing in rural Pakistan in managing patients with type 2 diabetes and supporting their management activities. Healthcare professionals and patients may benefit by adopting a methodological framework approach to ensure meaningful participation and adjusting the patient–doctor relationship, and setting up achievable management and self-management goals.

The poor quality of diabetes care in a cluster randomized community survey from Delhi (DEDICOM-II): A crisis, an opportunity

AIMS

To evaluate the quality of care in known diabetes patients of Delhi.

METHODS

A cross-sectional survey was conducted using a two-stage cluster design. In all, 30 of 150 wards were chosen in Stage 1 (using a random computer-generated seed value and then selecting wards at a predefined sampling interval; Probability Proportionate to Size-Systematic) and one colony from each ward was selected randomly in Stage 2. The selected areas were surveyed house-to-house in one-of-four random directions to recruit a minimum of 25 subjects (known diabetes ≥1 year; 35-65 years of age) per area. Data were collected by interview, blood sampling and from medical records by specifically trained research staff.

RESULTS

A total of 843 subjects (of 1315 eligible) were enrolled from 11,490 houses. For the intermediate outcome measures, an estimated 33.5% (95% CI 27.3-40.2) had an HbA_1c value >10%, 67.2% (95% CI 62.8-71.4) had an LDL cholesterol level >100 mg/dl and 57.3% (95% CI 50.4-63.9) had BP levels >140/90 mmHg. For the processes of care in the last 1 year, 25.6% (95% CI 19.7-32.6) of the patients had an HbA_1c (A1c) estimation and 2.4% (95% CI 1.1-4.9) had a dilated eye examination and 4.1% (95% CI 2.6-6.2) had foot examination. Diabetes self-management education was provided to only 11.3% (95% CI 8.6-14.7) while nutrition counselling was provided to 56.0% (95% CI 51.7-60.2).

CONCLUSIONS

The glycaemic control, lipid control and BP management of known diabetes patients in Delhi are unacceptably poor and a wide gap exists between practice recommendations and delivery of diabetes care in Delhi.

Decentralizing diabetes care from tertiary to primary care: how many persons with diabetes can be down-referred to primary care settings?

BACKGROUND

In a cohort of persons with diabetes (PWDs) seeking care at a tertiary care center, we aimed to determine the proportion of PWDs eligible and willing for down referral to primary health centers (PHCs).

METHODS

We conducted a cross-sectional analytical study among PWDs on treatment for at least 1 year. PWDs with stable blood sugar, no history of cardiovascular events and proliferative retinopathy were considered as 'eligible' for primary care management.

RESULTS

Of the total 1002 PWDs, mean (SD) age was 56 (12) years; 62% were male and 81% were from rural areas. About half (49%) of them were on insulin, and 52% had comorbidities. In total, 45.6% (95% CI: 42.3-48.8%) were eligible to be managed at PHCs. Among those who were eligible, 46.6% were willing to go back to PHCs. Males (APR = 1.16), people with diabetes for more than 10 years (APR = 1.23), and the presence of comorbidities (APR = 1.13) were significantly associated with unwillingness. Quality of medicines (46%) and poor facilities (40%) at PHCs were the main reasons for unwillingness.

CONCLUSIONS

About half of the PWDs availing care at tertiary hospitals can be managed at primary care settings; of those, only half were willing to receive care at PHCs.

Association of Race/Ethnicity, Gender, and Socioeconomic Status With Sodium-Glucose Cotransporter 2 Inhibitor Use Among Patients With Diabetes in the US

IMPORTANCE

Sodium-glucose cotransporter 2 (SGLT2) inhibitors significantly reduce deaths from cardiovascular conditions, hospitalizations for heart failure, and progression of kidney disease among patients with type 2 diabetes. Black individuals have a disproportionate burden of cardiovascular and chronic kidney disease (CKD). Adoption of novel therapeutics has been slower among Black and female patients and among patients with low socioeconomic status than among White or male patients or patients with higher socioeconomic status.

OBJECTIVE

To assess whether inequities based on race/ethnicity, gender, and socioeconomic status exist in SGLT2 inhibitor use among patients with type 2 diabetes in the US.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of commercially insured patients in the US was performed from October 1, 2015, to June 30, 2019, using the Optum Clinformatics Data Mart. Adult patients with a diagnosis of type 2 diabetes, including those with heart failure with reduced ejection fraction (HFrEF), atherosclerotic cardiovascular disease (ASCVD), or CKD, were evaluated in the analysis.

MAIN OUTCOMES AND MEASURES

Prescription of an SGLT2 inhibitor. Multivariable logistic regression models were used to assess the association of race/ethnicity, gender, and socioeconomic status with SGLT2 inhibitor use.

RESULTS

Of 934 737 patients with type 2 diabetes (mean [SD] age, 65.4 [12.9] years; 50.7% female; 57.6% White), 81 007 (8.7%) were treated with an SGLT2 inhibitor during the study period. Between 2015 and 2019, the percentage of patients with type 2 diabetes treated with an SGLT2 inhibitor increased from 3.8% to 11.9%. Among patients with type 2 diabetes and cardiovascular or kidney disease, the rate of SGLT2 inhibitor use increased but was lower than that among all patients with type 2 diabetes (HFrEF: 1.9% to 7.6%; ASCVD: 3.0% to 9.8%; CKD: 2.1% to 7.5%). In multivariable analyses, Black race (adjusted odds ratio [aOR], 0.83; 95% CI, 0.81-0.85), Asian race (aOR, 0.94; 95% CI, 0.90-0.98), and female gender (aOR, 0.84; 95% CI, 0.82-0.85) were associated with lower rates of SGLT2 inhibitor use, whereas higher median household income (≥$100 000: aOR, 1.08 [95% CI, 1.05-1.10]; $50 000-$99 999: aOR, 1.05 [95% CI, 1.03-1.07] vs <$50 000) was associated with a higher rate of SGLT2 inhibitor use. These results were similar among patients with HFrEF, ASCVD, and CKD.

CONCLUSIONS AND RELEVANCE

In this cohort study, use of an SGLT2 inhibitor treatment increased among patients with type 2 diabetes from 2015 to 2019 but remained low, particularly among patients with HFrEF, CKD, and ASCVD. Black and female patients and patients with low socioeconomic status were less likely to receive an SGLT2 inhibitor, suggesting that interventions to ensure more equitable use are essential to prevent worsening of well-documented disparities in cardiovascular and kidney outcomes in the US.

Diabetes Management in Community Health Centers: a Review of Policies and Programs

PURPOSE OF REVIEW

Community health centers (CHCs) provide care to millions of vulnerable patients in the USA, including a disproportionate number with diabetes. Policies affecting diabetes management in CHCs therefore have broad implications for clinical practice and patient outcomes nationwide. We describe prior policies that have influenced diabetes management in CHCs, discuss current policies and programs, as well as present emerging innovations and future directions for diabetes care in this setting.

RECENT FINDINGS

Domains for current diabetes policies and programs in CHCs include coverage requirements, quality reporting and incentives, prescription discounts, healthy behavior incentives, and team-based care. Policies in these areas affect the management of diabetes at multiple levels, from organizations that support CHCs to individual health centers, and the providers and patients based there. Several domains of interrelated policies and programs impact CHC diabetes management at multiple levels. Stakeholders' understanding of these policies and programs may identify opportunities to improve diabetes care.

Social Risk Adjustment of Quality Measures for Diabetes and Cardiovascular Disease in a Commercially Insured US Population

IMPORTANCE

Patients' social risk factors may be associated with physician group performance on quality measures.

OBJECTIVE

To examine the association of social risk with change in physician group performance on diabetes and cardiovascular disease (CVD) quality measures in a commercially insured population.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study using claims data from 2010 to 2014 from a US national health insurance plan, the performance of 1400 physician groups (physicians billing under the same tax identification number) was estimated. After base adjustments for age and sex, changes in variation across groups and reordering of rankings resulting from additional adjustments for clinical, social, or both clinical and social risk factors were analyzed. In all models, only within-group associations were adjusted to distinguish the association of patients' social risk factors with outcomes while excluding physician groups' distinct characteristics that could also change observed performance. Data analysis was conducted between April and July 2018.

MAIN OUTCOMES AND MEASURES

Process measures (hemoglobin A1c [HbA1c] testing, low-density lipoprotein cholesterol [LDL-C] testing, and statin use), disease control measures (HbA1c and LDL-C level control), and use-based outcome measures (hospitalizations for ambulatory-sensitive conditions) were calculated with base adjustment (age and sex), clinical adjustment, social risk factor adjustment, and both clinical and social adjustments. Quality variance in physician group performance and changes in rankings following these adjustments were measured.

RESULTS

This study identified 1 684 167 enrollees (859 618 [51%] men) aged 18 to 65 years (mean [SD] age, 50 [10.7] years) with diabetes or CVD. Performance rates were high for HbA1c and LDL-C level testing (mean ranged from 79.5% to 87.2%) but lower for statin use (54.7% for diabetes cohort and 44.2% for CVD cohort) and disease control measures (57.9% on LDL-C control for diabetes cohort and 40.0% for CVD cohort). On average, only 8.8% of enrollees with diabetes and 1.0% of enrollees with CVD in a group were hospitalized. The addition of clinical and social risk factors to base adjustment reduced variance across physician groups for most measures (percentage change in SD ranged from -13.9% to 1.6%). Although overall agreement between performance scores with base vs full adjustment was high, there was still substantial reordering for some measures. For example, social risk adjustment resulted in reordering for disease control in the diabetes cohort. Of the 1400 physician groups, 330 (23.6%) had performance rankings for HbA1c control that increased or decreased by at least 10 percentile points after adding social risk factors to age and sex. Both clinical and social risk adjustment affected rankings on hospital admissions.

CONCLUSIONS AND RELEVANCE

Accounting for social risk may be important to mitigate adverse consequences of performance-based payments for physician groups serving socially vulnerable populations.

Improving inter-organizational care-cure designs: specialization versus integration

Purpose

The purpose of this paper is to investigate inter-organizational designs for care–cure conditions in which low-risk patients are cared for in specialized care organizations and high-risk patients are cared for in specialized cure organizations. Performance impacts of increasing levels of integration between these organizations are analyzed.

Design/methodology/approach

Mixed methods were used in Dutch perinatal care: analysis of archival data, clinical research and system dynamics simulation modeling.

Findings

Inter-organizational design has an effect on inter-organizational dynamics such as collaboration and trust, and also on the operational aspects such as patient flows through the system. Solutions are found in integrating care and cure organizations. However, not all levels of integrated designs perform better than a design based on organizational separation of care and cure.

Practical implications

A clear split between midwifery practices (care) and obstetric departments (cure) will not work since all pregnant women need both care and cure. Having midwifery practices only works well when there are high levels of collaboration and trust with obstetric departments in hospitals. Integrated care designs are likely to exhibit superior performance. However, these designs will have an adverse effect on organizations that are not part of this integration, since integrating only a subset of organizations will feed distrust, low collaboration and hence low performance.

Originality/value

The originality of this research is derived from its multi-method approach. Archival data and clinical research revealed the dynamic relations between organizations. The caveat of some integrated care models was found through simulation.

Value-based payment in implementing evidence-based care: the Mental Health Integration Program in Washington state

OBJECTIVES

To assess the role of value-based payment (VBP) in improving fidelity and patient outcomes in community implementation of an evidence-based mental health intervention, the Collaborative Care Model (CCM).

STUDY DESIGN

Retrospective study based on a natural experiment.

METHODS

We used the clinical tracking data of 1806 adult patients enrolled in a large implementation of the CCM in community health clinics in Washington state. VBP was initiated in year 2 of the program, creating a natural experiment. We compared implementation fidelity (measured by 3 process-of-care elements of the CCM) between patient-months exposed to VBP and patient-months not exposed to VBP. A series of regressions were estimated to check robustness of findings. We estimated a Cox proportional hazard model to assess the effect of VBP on time to achieving clinically significant improvement in depression (measured based on changes in depression symptom scores over time).

RESULTS

Estimated marginal effects of VBP on fidelity ranged from 9% to 30% of the level of fidelity had there been no exposure to VBP (P <.05 for every fidelity measure). Improvement in fidelity in response to VBP was greater among providers with a larger patient panel and among providers with a lower level of fidelity at baseline. Exposure to VBP was associated with an adjusted hazard ratio of 1.45 (95% confidence interval, 1.04-2.03) for achieving clinically significant improvement in depression.

CONCLUSIONS

VBP improved fidelity to key elements of the CCM, both directly incentivized and not explicitly incentivized by the VBP, and improved patient depression outcomes.

Physician-Patient Racial Matching, Effectiveness of Care, Use of Services, and Patient Satisfaction

The authors examined how racial matching between older patients and physicians relates to effectiveness of care, use of services, and satisfaction with care. In this cross-sectional, community-based cohort study, 2,867 elderly African American and White North Carolina residents with regular physicians were interviewed and screened for hypertension (HBP). African Americans were more likely than Whites to be told they had HBP, to receive HBP medication, and to take it regardless of their physician’s race. White elders with African American physicians were more likely to report that they delayed care quite often. African American elders were less likely to delay care quite often, regardless of their physicians’ race. These results did not support the position that African Americans require treatment by African American physicians to achieve better care. Although elders of both races who had African American physicians were less satisfied with care received, interpretation of this finding is difficult without better measurement of patient satisfaction.

Insurance, racial/ethnic, SES-related disparities in quality of care among US adults with diabetes

Diabetes-related quality improvement initiatives are typically aimed at improving outcomes and reducing complications. Studies have found that disparities in quality persist for certain racial/ethnic and socioeconomically disadvantaged groups; however, results are mixed with regard to insurance-based differences. The purpose of this study is to investigate the independent associations between type of health insurance coverage, race/ethnicity, and socioeconomic status (SES), and quality of care, as measured by benchmark indicators of diabetes-related primary care. This study used the Diabetes Care Survey of the 2010 Medical Expenditure Panel Survey. Bivariate and multivariate logistic regressions were used to examine the association between quality of diabetes care and type of insurance coverage, race/ethnicity, and SES. Multivariate analyses also controlled for additional demographic and health status characteristics. Respondents with insurance coverage (particularly those with private insurance or with Medicare and Medicaid coverage) were more likely to receive quality diabetes care than uninsured individuals. Few significant disparities based on race/ethnicity or SES persisted in subsequent multivariate analyses. Findings suggest that insurance coverage may make the greatest impact in ensuring equitable distribution of quality diabetes care, regardless of race/ethnicity or socioeconomic status. With the implementation of Affordable Care Act under which more people could potentially gain access to insurance, policymakers should next track insurance-based diabetes care disparities.

ADESÃO DE HIPERTENSOS E DIABÉTICOS ANALFABETOS AO USO DE MEDICAMENTO A PARTIR DA PRESCRIÇÃO PICTOGRÁFICA

Resumo A baixa adesão ao tratamento medicamentoso constitui grave entrave para o sucesso do controle de doenças como o diabetes e a hipertensão arterial. Este artigo trata de um estudo que partiu da identificação do analfabetismo como importante causa de não adesão ao tratamento medicamentoso para diabéticos e hipertensos participantes do programa Hiperdia em unidade de saúde do município de Colombo, no estado do Paraná. Teve como objetivo avaliar o impacto de prescrição pictórica na adesão ao tratamento. Analisou-se um grupo de 63 diabéticos e hipertensos que participavam do Hiperdia, para os quais aplicou-se uma entrevista estruturada, com posterior análise do conteúdo, antes e depois da implantação de uma prescrição pictográfica. Como resultado, entre os analfabetos, observou-se a elevação da adesão de 60% para 93,33% em relação ao tratamento medicamentoso. No grupo de alfabetizados não houve mudança na adesão. Conclui-se, no entanto, que esse tipo de intervenção é limitado para a melhora da condição de saúde dos pacientes, pois o aumento da adesão se dá em relação tanto ao tratamento medicamentoso quanto à precariedade.

Building the evidence for integrated care for type 2 diabetes: a pilot study

Integrated care models have the potential to reduce fragmentation in the health system and improve outcomes for people with type 2 diabetes. A pilot evaluation of an integrated care model for people with type 2 diabetes in Melbourne, Australia, is reported on. Two studies were conducted: (1) a 6-month pilot randomised controlled trial (n=56) evaluating the impact of the integrated care model relative to hospital outpatient clinics; and (2) a cross-sectional study (n=92) of patients attending the two services. The primary outcome was diabetes-specific distress; secondary outcomes were perceived quality of diabetes care, diabetes-specific self-efficacy and glycated haemoglobin (HbA1c). There was no effect of service setting on diabetes-specific distress. Participants from the integrated care setting perceived the quality of diabetes care to be higher than did participants from the hospital clinics. Significant HbA1c improvements were observed over time, but with no effect of service setting. The model holds promise for people with type 2 diabetes who need more specialist/multidisciplinary care than can be provided in primary care. Patients’ evaluations of the quality of diabetes care received at the integrated care service are very positive, which is likely to be one of the key strengths of the integrated model.

Quality and Cost of Diabetes Mellitus Care in Community Health Centers in the United States

OBJECTIVE

To examine variations in the quality and cost of care provided to patients with diabetes mellitus by Community Health Centers (CHCs) compared to other primary care settings.

RESEARCH DESIGN AND METHODS

We used data from the 2005-2008 Medical Expenditure Panel Survey (N = 2,108). We used two dependent variables: quality of care and ambulatory care expenditures. Our primary independent variable was whether the respondent received care in a Community Health Centers (CHCs) or not. We estimated logistic regression models to determine the probability of quality of care, and used generalized linear models with log link and gamma distribution to predict expenditures for CHC users compared to non-users of CHCs, conditional on patients with positive expenditures.

RESULTS

Results showed that variations of quality between CHC users and non-CHC users were not statistically significant. Patients with diabetes mellitus who used CHCs saved payers and individuals approximately $1,656 in ambulatory care costs compared to non-users of CHCs.

CONCLUSIONS

These findings suggest an opportunity for policymakers to control costs for diabetes mellitus patients without having a negative impact on quality of care.

Quality of Diabetic Care among Patients in a Tertiary Care Hospital in Bangalore, South India: A Cross-sectional Study

BACKGROUND

Despite high prevalence of diabetes, translation of practice recommendations to care is still deficient in Asian and developed countries. The objective of this study is to assess the quality of care provided to diabetic patients and extent of knowledge transfer by the provider to these patients as a measure of the quality of service.

MATERIALS AND METHODS

A cross sectional study was done among 190 diabetic patients over a period of 6 months. All type II diabetic patients, 30 years and above, who were diagnosed at least 1 year back without any other co-morbidity satisfied the inclusion criteria. They were interviewed based on an audit checklist formulated by National Diabetes Quality Improvement Alliance.

RESULTS

The results revealed that blood pressure is the only parameter which is regularly monitored in majority (93%) of the diabetics. Hb1AC, LDL cholesterol and eye check up were less common and done only in 40%, 52.6% and 56.8% of diabetics respectively. Only 33(17.37%) had at least 5 of the 7 essential parameters monitored at least once in the last year. The knowledge questionnaire showed that more than 70% of the diabetic patients know that their condition requires lifelong management, diet modifications and exercises. There was no difference in the knowledge scores between the people who had no essential tests done and those diabetics who got 5 essential tests done. Gender, education, occupation and duration of diabetes were associated with knowledge score.

CONCLUSION

There is a need to formulate the local standards of care and clinical practice guidelines for the management of diabetes that are easily affordable and available to the health care providers and applicable to our country at the national level. Continuing audit of patients with diabetes is a feasible and a very useful method of promoting and helping to achieve the management goals of a good quality care.

Effect of Intensive Versus Standard Blood Glucose Control in Patients With Type 2 Diabetes Mellitus in Different Regions of the World: Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Regional variation in type 2 diabetes mellitus care may affect outcomes in patients treated with intensive versus standard blood glucose control. We sought to evaluate these differences between North America and the rest of the world.

METHODS AND RESULTS

Databases were searched from their inception through December 2013. Randomized controlled trials comparing the effects of intensive therapy with standard therapy for macro- and microvascular complications in adults with type 2 diabetes mellitus were selected. We calculated summary odds ratios (ORs) and 95% CIs with the random-effects model. The analysis included 34 967 patients from 17 randomized controlled trials (7 in North America and 10 in the rest of the world). There were no significant differences between intensive and standard therapy groups for all-cause mortality (OR 1.03, 95% CI 0.93 to 1.13) and cardiovascular mortality (OR 1.09, 95% CI 0.90 to 1.32). For trials conducted in North America, intensive therapy compared with standard glycemic control resulted in significantly higher all-cause mortality (OR 1.21, 95% CI 1.05 to 1.40) and cardiovascular mortality (OR 1.41, 95% CI 1.05 to 1.90) than trials conducted in the rest of the world (all-cause mortality OR 0.93, 95% CI 0.85 to 1.03; interaction P=0.006; cardiovascular mortality OR 0.89, 95% CI, 0.79 to 1.00; interaction P=0.007). Analysis of individual macro- and microvascular outcomes revealed no significant regional differences; however, the risk of severe hypoglycemia was significantly higher in trials of intensive therapy in North America (OR 3.52, 95% CI 3.07 to 4.03) compared with the rest of the world (OR 1.45, 95% CI 0.85 to 2.47; interaction P=0.001).

CONCLUSION

Randomization to intensive glycemic control in type 2 diabetes mellitus patients was associated with increases in all-cause mortality, cardiovascular mortality, and severe hypoglycemia in North America compared with the rest of the world. Further investigation into the pathobiology or patient variability underlying these findings is warranted.

The War on Poverty's Experiment in Public Medicine: Community Health Centers and the Mortality of Older Americans

This paper uses the rollout of the first Community Health Centers (CHCs) to study the longer-term health effects of increasing access to primary care. Within ten years, CHCs are associated with a reduction in age-adjusted mortality rates of 2 percent among those 50 and older. The implied 7 to 13 percent decrease in one-year mortality risk among beneficiaries amounts to 20 to 40 percent of the 1966 poor/non-poor mortality gap for this age group. Large effects for those 65 and older suggest that increased access to primary care has longer-term benefits, even for populations with near universal health insurance. (JEL H75, I12, I13, I18, I32, I38, J14).

Policy dilemmas in Latino health care and implementation of the Affordable Care Act

The changing Latino demographic in the United States presents a number of challenges to health care policy makers, clinicians, organizations, and other stakeholders. Studies have demonstrated that Latinos tend to have worse patterns of access to, and utilization of, health care than other ethnic and racial groups. The implementation of the Affordable Care Act (ACA) of 2010 may ameliorate some of these disparities. However, even with the ACA, it is expected that Latinos will continue to have problems accessing and using high-quality health care, especially in states that are not expanding Medicaid eligibility as provided by the ACA. We identify four current policy dilemmas relevant to Latinos' health and ACA implementation: (a) the need to extend coverage to the undocumented; (b) the growth of Latino populations in states with limited insurance expansion;

Self-awareness of foot health status in patients with Type 2 diabetes: the Fremantle Diabetes Study Phase II

AIMS

To determine self-awareness of diabetes-related foot problems and its associates in a community-based cohort of people with Type 2 diabetes.

METHODS

A survey concerning diabetic foot problems was administered to 358 consecutive patients with Type 2 diabetes [mean ± SD age 67.4 ± 10.8 years, 56.1% males, median (interquartile range) diabetes duration 9.0 (3.9-16.8) years] attending for detailed clinical, biochemical and questionnaire assessment as part of the longitudinal observational Fremantle Diabetes Study Phase II.

RESULTS

Compared with the 213 patients (59.5%) who considered their feet to be normal, the 145 (40.5%) who considered their feet to be abnormal were older, had longer diabetes duration and were more likely to have sensory neuropathic symptoms and self-reported poor circulation (P < 0.001). In those who considered their feet to be normal, 67.9% had peripheral sensory neuropathy (score >2/8 on the Michigan Neuropathy Screening Instrument clinical portion), 9.9% had an ankle-brachial index < 0.9, 6.1% had both peripheral sensory neuropathy and an ankle-brachial index < 0.90, and 86.9% had one or more features on inspection, such as deformity, dry skin, callus and fissures that could facilitate more serious complications, despite the majority having had at least one foot examination by a healthcare professional in the previous year.

CONCLUSIONS

Self-assessment of diabetes-related foot problems by patients in the Fremantle Diabetes Study Phase II was unreliable. The present data suggest that self-perceived foot health should be assessed together with foot examination findings. Intensive education and monitoring may be necessary in those who consider their feet to be normal but who have neurovascular, structural and/or other precursors of serious foot pathology.

Identifying diabetics in Medicare claims and survey data: implications for health services research

Background

Diabetes health services research often utilizes secondary data sources, including survey self-report and Medicare claims, to identify and study the diabetic population, but disagreement exists between these two data sources. We assessed agreement between the Chronic Condition Warehouse diabetes algorithm for Medicare claims and self-report measures of diabetes. Differences in healthcare utilization outcomes under each diabetes definition were also explored.

Methods

Claims data from the Medicare Beneficiary Annual Summary File were linked to survey and blood data collected from the 2006 Health and Retirement Study. A Hemoglobin A1c reading, collected on 2,028 respondents, was used to reconcile discrepancies between the self-report and Medicare claims measures of diabetes. T-tests were used to assess differences in healthcare utilization outcomes for each diabetes measure.

Results

The Chronic Condition Warehouse (CCW) algorithm yielded a higher rate of diabetes than respondent self-reports (27.3 vs. 21.2, p < 0.05). A1c levels of discordant claims-based diabetics suggest that these patients are not diabetic, however, they have high rates of healthcare spending and utilization similar to diabetics.

Conclusions

Concordance between A1c and self-reports was higher than for A1c and the CCW algorithm. Accuracy of self-reports was superior to the CCW algorithm. False positives in the claims data have similar utilization profiles to diabetics, suggesting minimal bias in some types of claims-based analyses, though researchers should consider sensitivity analysis across definitions for health services research.

Telemedicine and ocular health in diabetes mellitus

Teleretinal/teleophthalmological programs that use existing health information technology infrastructure solutions for people with diabetes increase access to and adherence to appropriate eye care. Teleophthalmological studies indicate that the single act of patients viewing their own retinal images improves self-management behaviour and clinical outcomes. In some settings this can be done at lower cost and with improved visual outcomes compared with standard eye care. Cost-effective and sustainable teleretinal surveillance for detection of diabetic retinopathy requires a combination of an inexpensive portable device for taking low light-level retinal images without the use of pharmacological dilation of the pupil and a computer-assisted methodology for rapidly detecting and diagnosing diabetic retinopathy. A more holistic telehealth-care paradigm augmented with the use of health information technology, medical devices, mobile phone and mobile health applications and software applications to improve health-care co-ordination, self-care management and education can significantly impact a broad range of health outcomes, including prevention of diabetes-associated visual loss. This approach will require a collaborative, transformational, patient-centred health-care program that integrates data from medical record systems with remote monitoring of data and a longitudinal health record. This includes data associated with social media applications and personal mobile health technology and should support continuous interactions between the patient, health-care team and the patient's social environment. Taken together, this system will deliver contextually and temporally relevant decision support to patients to facilitate their well-being and to reduce the risk of diabetic complications.

Clinical quality performance in U.S. health centers

OBJECTIVE

To describe current clinical quality among the nation's community health centers and to examine health center characteristics associated with performance excellence.

DATA SOURCES

National data from the 2009 Uniform Data System.

DATA COLLECTION/EXTRACTION METHODS

Health centers reviewed patient records and reported aggregate data to the Uniform Data System.

STUDY DESIGN

Six measures were examined: first-trimester prenatal care, childhood immunization completion, Pap tests, low birth weight, controlled hypertension, and controlled diabetes. The top 25 percent performing centers were compared with lower performing (bottom 75 percent) centers on these measures. Logistic regressions were utilized to assess the impact of patient, provider, and institutional characteristics on health center performance.

PRINCIPAL FINDINGS

Clinical care and outcomes among health centers were generally comparable to national averages. For instance, 67 percent of pregnant patients received timely prenatal care (national = 68 percent), 69 percent of children achieved immunization completion (national = 67 percent), and 63 percent of hypertensive patients had blood pressure under control (national = 48 percent). Depending on the measure, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well.

CONCLUSIONS

Health centers provide quality care at rates comparable to national averages. Performance may be improved by increasing insurance coverage among patients and increasing the ratios of physicians and enabling service providers to patients.

Diabetes Implementation of a Self-management Program in Resource Poor and Rural Community Clinics

PURPOSE

To evaluate the implementation of a brief diabetes self-management support intervention designed for resource-poor community clinics.

METHODS

The authors conducted a pilot study among patients with type 2 diabetes in 3 community clinics. The intervention consisted of research assistants introducing and reviewing a diabetes self-management guide, helping patients set an achievable behavioral action plan, and following up with 2 telephone sessions. The primary outcome was patients' success setting and achieving behavioral goals.

RESULTS

All participants set an action plan (N = 247); most focused on physical activity or diet (97%). The initial session took an average of 15 minutes. At 2 to 4 weeks, 200 participants were contacted; 68% recalled their action plan; and 84% of these achieved it. At 6 to 9 weeks, approximately half of those who completed the first call were reached for the second call. Of those who remained in the intervention, 79% recalled their action plan, and 80% of these achieved it. At the end of the study, 62% of those initially enrolled reported behavior change. Most participants who did not complete the intervention could not be reached for telephone follow-up.

CONCLUSIONS

Although only about a third of patients remained engaged through the 2 follow-up calls, most of those who did reported they had achieved their action plan. This pilot study provides insight into initiating brief diabetes self-management strategies in resource-poor community clinics. Although telephone follow-up was challenging, using the self-management guide and action plan framework, particularly during the initial clinic visit, helped focus patients on behavior change.

Quality improvement implementation and disparities: the case of the health disparities collaboratives

BACKGROUND

The Health Disparities Collaboratives (HDCs), a quality improvement (QI) collaborative incorporating rapid QI, a chronic care model, and learning sessions, have been implemented in over 900 community health centers across the country.

OBJECTIVES

To determine the HDC's effect on clinical processes and outcomes, their financial impact, and factors important for successful implementation.

RESEARCH DESIGN

Systematic review of the literature.

RESULTS

The HDCs improve clinical processes of care over short-term period of 1 to 2 years, and clinical processes and outcomes over longer period of 2 to 4 years. Most participants perceive that the HDCs are successful and worth the effort. Analysis of the Diabetes Collaborative reveals that it is societally cost-effective, with an incremental cost-effectiveness ratio of $33,386 per quality-adjusted life year, but that consistent revenue streams for the initiative do not exist. Common barriers to improvement include lack of resources, time, and staff burnout. Highest ranked priorities for more funding are money for direct patient services, data entry, and staff time for QI. Other common requests for more assistance are help with patient self-management, information systems, and getting providers to follow guidelines. Relatively low-cost ways to increase staff morale and prevent burnout include personal recognition, skills development opportunities, and fair distribution of work.

CONCLUSIONS

The HDCs have successfully improved quality of care, and the Diabetes Collaborative is societally cost-effective, but policy reforms are necessary to create a sustainable business case for these health centers that serve many uninsured and underinsured populations.

An explanatory model for state Medicaid per capita prescription drug expenditures

Rising prescription drug expenditure is a growing concern for publicly funded drug benefit programs like Medicaid. To be able to contain drug expenditures in Medicaid, it is important that cause(s) for such increases are identified. This study attempts to establish an explanatory model for Medicaid prescription drugs expenditure based on the impacts of key influencers/predictors identified using a comprehensive framework of drug utilization. A modified Andersen's behavior model of health services utilization is employed to identify potential determinants of pharmaceutical expenditures in state Medicaid programs. Level of federal matching funds, access to primary care, severity of diseases, unemployment, and education levels were found to be key influencers of Medicaid prescription drug expenditure. Increases in all, except education levels, were found to result in increases in drug expenditures. Findings from this study could better inform intervention policies and cost-containment strategies for state Medicaid drug benefit programs.

Addressing diabetes racial and ethnic disparities: lessons learned from quality improvement collaboratives

A review of national data confirms that while the quality of healthcare in the USA is slowly improving, disparities in diabetes prevalence, processes of care and outcomes for racial/ethnic minorities are not. Many quality measures can be addressed through system level interventions, referred to as quality improvement (QI), and QI collaboratives have been found to effectively improve processes of care for chronic conditions, including diabetes. However, the impact of QI collaboratives on the reduction of health disparities has been mixed. Lessons learned from previous QI collaboratives including the complexity of impacting clinical outcomes, the need for expert support for skills outside of QI methodology, limiting impact of poor data, and the need to develop disparities quality measures, can be used to inform future QI collaborative approaches to reduce diabetes racial/ethnic minority health disparities.

Adherence to clinical practice guidelines and outcomes in diabetic patients

OBJECTIVE

To examine the level of adherence to clinical practice guidelines and its relationship to outcomes in patients with diabetes.

DESIGN

Retrospective cohort study.

SETTING

A tertiary teaching hospital in Korea.

PARTICIPANTS

Patients aged ≥18 years with diabetes (n = 4994) who visited the study hospital once or more during 2004.

MAIN OUTCOME MEASURES

The outcomes were mortality from the database of the Statistics Korea and end-stage renal disease (ESRD) incidence from ESRD registry in the Korean Society of Nephrology until December 2009.

RESULTS

Testing rates for blood pressure, eye examination, HbA1c, renal function and lipid profiles were 93.9, 32.8, 84.9, 33.5 and 45.9%, respectively. The percentage of patients achieving each treatment goal was 27.8% for blood pressure, 44.2% for HbA1c and 49.4% for low-density lipoprotein (LDL) cholesterol. There were 11.7% patients with composite outcome (death and/or ESRD). Male gender, level of HbA1c (<7%), presence of HbA1c data, checking eye examination, presence of data on urine albumin-to-creatinine ratio (UACR) and having anti-platelet medication were associated with better outcome.

CONCLUSIONS

The adherence to recommendations was unsatisfactory, especially in checking eye examination, testing UACR and LDL cholesterol, and achieving a target goal for each parameter. Guideline adherence was positively related to better prognosis. Active strategies to apply the guidelines to clinical practice should be developed to improve patient outcomes.

Diabetes care and outcomes: disparities across rural America

We examined differences in receipt of diabetes care and selected outcomes between rural and urban persons living with diabetes, using nationally representative data from the 2006 Behavioral Risk Factor Surveillance System (BRFSS). "Rural" was defined as living in a non-metropolitan county. Diabetes care variables were physician visit, HbA1c testing, foot examination, and dilated eye examination. Outcome variables were presence of foot sores and diabetic retinopathy. Analysis was limited to persons 18 and older self-reporting a diagnosis of diabetes (n = 29,501). A lower proportion of rural than urban persons with diabetes reported a dilated eye examination (69.1 vs. 72.4%; P = 0.005) or a foot examination in the past year (70.6 vs. 73.7%; P = 0.016). Conversely, a greater proportion of rural than urban persons reported diabetic retinopathy (25.8 vs. 22.0%; P = 0.007) and having a foot sore taking more than four weeks to heal (13.2 vs. 11.2%; P = 0.036). Rural residence was not associated with receipt of services after individual characteristics were taken into account in adjusted analysis, but remained associated with an increased risk for retinopathy (OR = 1.20, 95% CI = 1.02-1.42). Participation in Diabetes Self-Management Education (DSME) was positively associated with all measures of diabetes care included in the study. Availability of specialty services and travel considerations could explain some of these differences.

The influence of literacy on patient-reported experiences of diabetes self-management support

BACKGROUND

Variability in disease-related outcomes may relate to how patients experience self-management support in clinical settings.

OBJECTIVES

The purpose of this study was to identify factors associated with experiences of self-management support during primary care encounters.

METHODS

A cross-sectional survey was conducted of 208 patients seen in a multidisciplinary diabetes program in an academic medicine clinic. Multiple regression analysis was used to test associations between patient-rated experiences of self-management support (Patient Assessment of Chronic Illness Care) and race, gender, insurance status, literacy, duration of diabetes, and intensity of care management.

RESULTS

The Patient Assessment of Chronic Illness Care ratings decreased with age (r = -.235, p = .001), were higher for women than for men (3.95 vs. 3.65, t = 2.612, p= .010), and were greater for those with more education (F= 3.927, p = .009) and greater literacy skills (t = 3.839, p< .001). The ratings did not vary between racial (t = -1.108, p = .269) or insurance (F = 1.045, p = .374) groups and were unaffected by the duration of diabetes (r= .052, p = .466) and the intensity of care management (F = 1.028, p = .360). In multivariate models, literacy was the only variable contributing significantly to variation in self-management support ratings.

DISCUSSION

Even when considering the objective intensity of health services delivered, literacy was the sole variable contributing to differences in patient ratings of self-management support. Although conclusions are limited by the cross-sectional nature of this study, the results emphasize the need to consider literacy when developing and communicating treatment plans requiring self-management skills.

Quality improvement implementation and disparities: the case of the health disparities collaboratives

BACKGROUND

The Health Disparities Collaboratives (HDCs), a quality improvement (QI) collaborative incorporating rapid QI, a chronic care model, and learning sessions, have been implemented in over 900 community health centers across the country.

OBJECTIVES

To determine the HDC's effect on clinical processes and outcomes, their financial impact, and factors important for successful implementation.

RESEARCH DESIGN

Systematic review of the literature.

RESULTS

The HDCs improve clinical processes of care over short-term period of 1 to 2 years, and clinical processes and outcomes over longer period of 2 to 4 years. Most participants perceive that the HDCs are successful and worth the effort. Analysis of the Diabetes Collaborative reveals that it is societally cost-effective, with an incremental cost-effectiveness ratio of $33,386 per quality-adjusted life year, but that consistent revenue streams for the initiative do not exist. Common barriers to improvement include lack of resources, time, and staff burnout. Highest ranked priorities for more funding are money for direct patient services, data entry, and staff time for QI. Other common requests for more assistance are help with patient self-management, information systems, and getting providers to follow guidelines. Relatively low-cost ways to increase staff morale and prevent burnout include personal recognition, skills development opportunities, and fair distribution of work.

CONCLUSIONS

The HDCs have successfully improved quality of care, and the Diabetes Collaborative is societally cost-effective, but policy reforms are necessary to create a sustainable business case for these health centers that serve many uninsured and underinsured populations.

The effects of a computer-tailored message on secondary prevention in type 2 diabetes: a randomized trial

The purpose of this study was to test the effect of computer-generated, tailored feedback on the quality of chronic disease management for type 2 diabetes when provided to a patient prior to a scheduled physician visit. A stand-alone computer application was developed to provide tailored feedback aimed at empowering patients to engage more actively in their diabetes management. Adults with type 2 diabetes (n = 203) were randomly assigned to groups receiving either efficacy (positive) messages (n = 68), risk (negative) messages (n = 67), or to a delayed treatment control group (n = 68). The intervention was delivered prior to a patient's visit with his or her physician so that patients would have the opportunity to discuss the messages at the clinical appointment. Although there were no significant differences in the percentage of participants who received intensified care or routine tests between the control and intervention groups, we learned that more directive messaging may be needed to help patients effectively manage their diabetes. Patients may benefit from directive feedback, providing them with specific questions to ask their physician that can lead to improved care, rather than receiving general and educational informational messages.

Missed opportunities in diabetes management: a longitudinal assessment of factors associated with sub-optimal quality

BACKGROUND

In diabetic adults, tight control of risk factors reduces complications.

OBJECTIVE

To determine whether failure to make visits, monitor risk factors, or intensify therapy affects control of blood pressure, glucose, and lipids.

DESIGN

A non-concurrent, prospective study of data from electronic files and standardized abstraction of hard-copy medical records for the period 1/1/1999-12/31/2001.

PARTICIPANTS

Three hundred eighty-three adults with diabetes managed in an academically affiliated managed care program.

MEASUREMENTS

Main exposure variable: Intensification of therapy or failure to intensify, reckoned on a quarterly basis.

MAIN OUTCOME MEASURE

Hemoglobin A1c (A1c), systolic blood pressure (SBP), and LDL-cholesterol at the end of the interval.

RESULTS

In this visit-adherent cohort, control of glycemia and lipids showed improvement over 24 months, but many patients did not achieve targets. Only those with the worst blood pressure control (SBP >or=160 mmHg) showed any improvement over 2 years. Failure to intensify treatment in patients who kept visits was the single strongest predictor of sub-optimal control. Compared to their counterparts with no failures of intensification, patients with failures in >or=3 quarters showed markedly worse control of blood glucose (A1c 1.4% higher: 95% CI: 0.7, 2.1); hypertension (SBP 22.2 mmHg higher: 95% CI: 16.6, 27.9) and LDL cholesterol (LDL 43.7 mg/dl higher: 95% CI: 24.1, 63.3). These relationships were strong, graded, and independent of socio-demographic factors, baseline risk factor values, and co-morbidities.

CONCLUSIONS

Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring. Interventions designed to promote appropriate intensification should enhance diabetes care in primary practice.

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.

Metabolic control in a nationally representative diabetic elderly sample in Costa Rica: patients at community health centers vs. patients at other health care settings

Background

Costa Rica, like other developing countries, is experiencing an increasing burden of chronic conditions such as diabetes mellitus (DM), especially among its elderly population. This article has two goals: (1) to assess the level of metabolic control among the diabetic population age ≥ 60 years old in Costa Rica, and (2) to test whether diabetic elderly patients of community health centers differ from patients in other health care settings in terms of the level of metabolic control.

Methods

Data come from the project CRELES, a nationally representative study of people aged 60 and over in Costa Rica. This article analyzes a subsample of 542 participants in CRELES with self-reported diagnosis of diabetes mellitus. Odds ratios of poor levels of metabolic control at different health care settings are computed using logistic regressions.

Results

Lack of metabolic control among elderly diabetic population in Costa Rica is described as follows: 37% have glycated hemoglobin ≥ 7%; 78% have systolic blood pressure ≥ 130 mmHg; 66% have diastolic blood pressure ≥ 80 mmHg; 48% have triglycerides ≥ 150 mg/dl; 78% have LDL ≥ 100 mg/dl; 70% have HDL ≤ 40 mg/dl. Elevated levels of triglycerides and LDL were higher in patients of community health centers than in patients of other clinical settings. There were no statistical differences in the other metabolic control indicators across health care settings.

Conclusion

Levels of metabolic control among elderly population with DM in Costa Rica are not that different from those observed in industrialized countries. Elevated levels of triglycerides and LDL at community health centers may indicate problems of dyslipidemia treatment among diabetic patients; these problems are not observed in other health care settings. The Costa Rican health care system should address this problem, given that community health centers constitute a means of democratizing access to primary health care to underserved and poor areas.

Measuring the Quality of Care of Diabetic Patients at the Specialist Outpatient Clinics in Public Hospitals in Singapore

Introduction: This study aims to measure the quality of care for patients with diabetes mellitus at selected Specialist Outpatient Clinics (SOCs) in the National Healthcare Group. Materials and Methods: The cross-sectional study reviewed case-records of patients from 6 medical specialties who were on continuous care for a minimum of 15 months from October 2003 to April 2005. Disproportionate sampling of 60 patients from each specialty, excluding those co-managed by Diabetes Centres or primary care clinics for diabetes, was carried out. Information on demographic characteristics, process indicators and intermediate outcomes were collected and the adherence rate for each process indicator compared across specialties. Data analysis was carried out using SPSS version 13.0. Results: A total of 575 cases were studied. The average rate for 9 process indicators by specialty ranged from 47.8% to 70.0%, with blood pressure measurement consistently high across all specialties (98.4%). There was significant variation (P <0.001) in rates across the specialties for 8 process indicators; HbA1c, serum creatinine and lipid profile tests were over 75%, while the rest were below 50%. The mean HbA1c was 7.3% ± 1.5%. “Optimal” control of HbA1c was achieved in 51.2% of patients, while 50.6% of the patients achieved “optimal” low-density lipoprotein (LDL)-cholesterol control. However, 47.3% of patients had “poor” blood pressure control. Adherence to process indicators was not associated with good intermediate outcomes. Conclusions: There was large variance in the adherence rate of process and clinical outcome indicators across specialties, which could be improved further. Key words: Assessment, Indicators, Outcome, Process

Diabetes health disparities: a systematic review of health care interventions

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

Diabetes health disparities: a systematic review of health care interventions

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

Diabetes health disparities: a systematic review of health care interventions

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

Role of lifestyle and oral anti-diabetic agents to prevent type 2 diabetes mellitus and cardiovascular disease

Patients with type 2 diabetes mellitus (DM) and those with impaired glucose tolerance are at increased risk for the development of cardiovascular disease. With an increasing global incidence and prevalence of type 2 DM, and with the 2003 lowering of the glucose threshold required for the diagnosis of impaired glucose tolerance to 100 mg/dl (5.6 mmol/L), the concept of DM prevention, and presumed reduction of cardiovascular risk, is attractive. However, there is little evidence to guide the choice of DM prevention strategy and no certainty that DM prevention will result in reduced cardiovascular events or an overall favorable balance of benefit to risk. In conclusion, this review examines previous reports on DM prevention, with special attention to evidence for cardiovascular event reduction in association with specific interventions to prevent DM.

Quality of diabetes care in the middle- and high-income group populace: the Delhi Diabetes Community (DEDICOM) survey

OBJECTIVE

We sought to evaluate the quality of care in known diabetic patients from the middle- and high-income group populace of Delhi.

RESEARCH DESIGN AND METHODS

A cross-sectional survey was conducted using a probability proportionate to size (systematic), two-stage cluster design. Thirty areas were selected for a house-to-house survey to recruit a minimum of 25 subjects (known diabetes >/= 1 year; aged 35-65 years) per area. Data were collected by interview, by blood sampling, and from medical records.

RESULTS

A total of 819 subjects (of 1,153 eligible) were enrolled from 20,666 houses. In total, 13.0% (95% CI 9.6-17.3) of the patients had an HbA(1c) (A1C) estimation and 16.2% (13.5-19.4) had a dilated eye examination in the last year, 32.1% (27.5-36.6) had serum cholesterol estimation in the last year, and 17.5% (14.2-21.5) were taking aspirin. An estimated 42.0% (37.7-46.2) had an A1C value >8%, 40.6% (36.5-44.7) had an LDL cholesterol level >130 mg/dl, and 63.2% (59.6-66.6) had blood pressure levels >140/90 mmHg.

CONCLUSIONS

A wide gap exists between practice recommendations and delivery of diabetes care in Delhi.