1
|
Konnyu KJ, Yogasingam S, Lépine J, Sullivan K, Alabousi M, Edwards A, Hillmer M, Karunananthan S, Lavis JN, Linklater S, Manns BJ, Moher D, Mortazhejri S, Nazarali S, Paprica PA, Ramsay T, Ryan PM, Sargious P, Shojania KG, Straus SE, Tonelli M, Tricco A, Vachon B, Yu CH, Zahradnik M, Trikalinos TA, Grimshaw JM, Ivers N. Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes. Cochrane Database Syst Rev 2023; 5:CD014513. [PMID: 37254718 PMCID: PMC10233616 DOI: 10.1002/14651858.cd014513] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations. OBJECTIVES To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care. SEARCH METHODS We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section. SELECTION CRITERIA We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy. DATA COLLECTION AND ANALYSIS We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors. Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available. MAIN RESULTS We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted. Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three. Combinations of the three most effective QI strategies were estimated to lead to the below effects: - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%; - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg; - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other). AUTHORS' CONCLUSIONS There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.
Collapse
Affiliation(s)
- Kristin J Konnyu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sharlini Yogasingam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Johanie Lépine
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Katrina Sullivan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Alun Edwards
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Michael Hillmer
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Sathya Karunananthan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - John N Lavis
- McMaster Health Forum, Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Stefanie Linklater
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Braden J Manns
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - David Moher
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Sameh Mortazhejri
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Samir Nazarali
- Department of Ophthalmology and Visual Sciences, University of Alberta, Edmonton, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Timothy Ramsay
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Peter Sargious
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Kaveh G Shojania
- University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Sharon E Straus
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
| | - Marcello Tonelli
- Department of Medicine and Community Health Sciences, University of Calgary, Calgary, Canada
| | - Andrea Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital and University of Toronto, Toronto, Canada
- Epidemiology Division and Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Queen's Collaboration for Health Care Quality: A JBI Centre of Excellence, Queen's University, Kingston, Canada
| | - Brigitte Vachon
- School of Rehabilitation, Occupational Therapy Program, University of Montreal, Montreal, Canada
| | - Catherine Hy Yu
- Department of Medicine, St. Michael's Hospital, Toronto, Canada
| | - Michael Zahradnik
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Thomas A Trikalinos
- Departments of Health Services, Policy, and Practice and Biostatistics, Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, Women's College Hospital, Toronto, Canada
| |
Collapse
|
2
|
Bell C, Prior A, Appel CW, Frølich A, Pedersen AR, Vedsted P. Multimorbidity and determinants for initiating outpatient trajectories: A population-based study. BMC Public Health 2023; 23:739. [PMID: 37085788 PMCID: PMC10120141 DOI: 10.1186/s12889-023-15453-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 03/15/2023] [Indexed: 04/23/2023] Open
Abstract
INTRODUCTION Individuals with multimorbidity often receive high numbers of hospital outpatient services in concurrent trajectories. Nevertheless, little is known about factors associated with initiating new hospital outpatient trajectories; identified as the continued use of outpatient contacts for the same medical condition. PURPOSE To investigate whether the number of chronic conditions and sociodemographic characteristics in adults with multimorbidity is associated with entering a hospital outpatient trajectory in this population. METHODS This population-based register study included all adults in Denmark with multimorbidity on January 1, 2018. The exposures were number of chronic conditions and sociodemographic characteristics, and the outcome was the rate of starting a new outpatient trajectory during 2018. Analyses were stratified by the number of existing outpatient trajectories. We used Poisson regression analysis, and results were expressed as incidence rates and incidence rate ratios with 95% confidence intervals. We followed the individuals during the entire year of 2018, accounting for person-time by hospitalization, emigration, and death. RESULTS Incidence rates for new outpatient trajectories were highest for individuals with low household income and ≥3 existing trajectories and for individuals with ≥3 chronic conditions and in no already established outpatient trajectory. A high number of chronic conditions and male gender were found to be determinants for initiating a new outpatient trajectory, regardless of the number of existing trajectories. Low educational level was a determinant when combined with 1, 2, and ≥3 existing trajectories, and increasing age, western ethnicity, and unemployment when combined with 0, 1, and 2 existing trajectories. CONCLUSION A high number of chronic conditions, male gender, high age, low educational level and unemployment were determinants for initiation of an outpatient trajectory. The rate was modified by the existing number of outpatient trajectories. The results may help identify those with multimorbidity at greatest risk of having a new hospital outpatient trajectory initiated.
Collapse
Affiliation(s)
- Cathrine Bell
- Diagnostic Centre - University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Central Denmark Region, Silkeborg, Danmark.
| | - Anders Prior
- Research Unit for General Practice, Aarhus, Denmark
| | - Charlotte Weiling Appel
- Diagnostic Centre - University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Central Denmark Region, Silkeborg, Danmark
| | - Anne Frølich
- Innovation and Research Centre for Multimorbidity, Slagelse Hospital, Region Zealand, Denmark
- Centre for General Practice, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Asger Roer Pedersen
- Diagnostic Centre - University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Central Denmark Region, Silkeborg, Danmark
| | - Peter Vedsted
- Diagnostic Centre - University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Central Denmark Region, Silkeborg, Danmark
- Research Unit for General Practice, Aarhus, Denmark
| |
Collapse
|
3
|
Grundman JB, Majidi S, Perkins A, Streisand R, Monaghan M, Marks BE. Applying the use of shared medical appointments (SMAs) to improve continuous glucose monitor (CGM) use, glycemic control, and quality of life in marginalized youth with type 1 diabetes: Study protocol for a pilot prospective cohort study. Contemp Clin Trials Commun 2023; 32:101067. [PMID: 36698741 PMCID: PMC9868328 DOI: 10.1016/j.conctc.2023.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/08/2022] [Accepted: 01/14/2023] [Indexed: 01/18/2023] Open
Abstract
Background Continuous glucose monitors (CGMs) have been associated with improved glycemic control and diabetes-related quality of life in youth with type 1 diabetes (T1D), however use is lowest among youth from low-income households and racial/ethnic minorities. Shared medical appointments (SMAs) have been shown to improve glycemic control and reduce diabetes distress in adolescents with T1D, but a focus on marginalized youth has been lacking. This prospective cohort pilot study will assess feasibility and acceptability of the SMA intervention and impact on CGM uptake and sustained use, glycemic control, and diabetes distress in marginalized youth with elevated hemoglobin A1c (HbA1C). Methods The pilot study will recruit 20 publicly insured youth with T1D aged 8-12 years who identify as non-Hispanic Black or Latinx and have had at least one HbA1C value > 8% in the past year and their primary caretaker. The trial will employ an enrollment visit, SMA visits every 3 months over a 12-month study period, and a 6-month follow-up observational period. Feasibility measures include proportion of eligible youth successfully recruited for participation, proportion initiating CGM, SMA attendance, and retention through study completion. Acceptability will be assessed using satisfaction surveys. Changes in glycemic control will be assessed using CGM metrics and A1c from baseline to completion of the 12-month SMA intervention, as well as 3 and 6-months after completion of the SMA intervention. Conclusion Implementing SMAs for marginalized youth has the potential to address diabetes disparities by optimizing clinical and psychosocial outcomes for the most vulnerable youth living with T1D.Trial Registration: https://clinicaltrials.gov/ct2/show/NCT05431686.
Collapse
Affiliation(s)
- Jody B. Grundman
- Division of Endocrinology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, USA,Corresponding author.
| | - Shideh Majidi
- Division of Endocrinology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, USA,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - Amanda Perkins
- Division of Endocrinology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, USA
| | - Randi Streisand
- Division of Endocrinology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, USA,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - Maureen Monaghan
- Division of Endocrinology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, USA
| | - Brynn E. Marks
- Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| |
Collapse
|
4
|
Goh LH, Siah CJR, Tam WWS, Tai ES, Young DYL. Effectiveness of the chronic care model for adults with type 2 diabetes in primary care: a systematic review and meta-analysis. Syst Rev 2022; 11:273. [PMID: 36522687 PMCID: PMC9753411 DOI: 10.1186/s13643-022-02117-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/02/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Mixed evidence exists regarding the effectiveness of the Chronic Care Model (CCM) with patient outcomes. The aim of this review is to examine the effectiveness of CCM interventions on hemoglobin A1c (HbA1c), systolic BP (SBP), diastolic BP (DBP), LDL cholesterol and body mass index (BMI) among primary care adults with type 2 diabetes. METHODS PubMed, Embase, CINAHL, Cochrane Central Registry of Controlled Trials, Scopus and Web of Science were searched from January 1990 to June 2021 for randomized controlled trials (RCTs) comparing CCM interventions against usual care among adults with type 2 diabetes mellitus in primary care with HbA1c, SBP, DBP, LDL cholesterol and BMI as outcomes. An abbreviated search was performed from 2021 to April 2022. This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines for data extraction and Cochrane risk of bias assessment. Two reviewers independently extracted the data. Meta-analysis was performed using Review Manager software. Heterogeneity was evaluated using χ2 and I2 test statistics. Overall effects were evaluated using Z statistic. RESULTS A total of 17 studies involving 16485 patients were identified. Most studies had low risks of bias. Meta-analysis of all 17 studies revealed that CCM interventions significantly decreased HbA1c levels compared to usual care, with a mean difference (MD) of -0.21%, 95% CI -0.30, -0.13; Z = 5.07, p<0.00001. Larger effects were experienced among adults with baseline HbA1c ≥8% (MD -0.36%, 95% CI -0.51, -0.21; Z = 5.05, p<0.00001) and when four or more CCM elements were present in the interventions (MD -0.25%, 95% CI -0.35, -0.15; Z = 4.85, p<0.00001). Interventions with CCM decreased SBP (MD -2.93 mmHg, 95% CI -4.46, -1.40, Z = 3.75, p=0.0002) and DBP (MD -1.35 mmHg, 95% CI -2.05, -0.65, Z = 3.79, p=0.0002) compared to usual care but there was no impact on LDL cholesterol levels or BMI. CONCLUSIONS CCM interventions, compared to usual care, improve glycaemic control among adults with type 2 diabetes in primary care, with greater reductions when the mean baseline HbA1c is ≥8% and with interventions containing four or more CCM elements. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021273959.
Collapse
Affiliation(s)
- Lay Hoon Goh
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Chiew Jiat Rosalind Siah
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Wilson Wai San Tam
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - E Shyong Tai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Doris Yee Ling Young
- Division of Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, NUHS Tower Block Level 9, 1E Kent Ridge Road, Singapore, 119228, Singapore
| |
Collapse
|
5
|
Beh YS, Gopalsamy K, Lee SLF, P Vengadasalam VP. Impact of Diabetes Medication Therapy Adherence Clinic (DMTAC) appointment intervals on glycemic control in public health clinics across Perak, Malaysia. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2022; 17:105-113. [PMID: 36606164 PMCID: PMC9809452 DOI: 10.51866/oa134l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Frequent diabetes medication therapy adherence clinic (DMTAC) appointments may lead to more rapid glycaemic control. This study aimed to evaluate the association between appointment intervals and glycaemic control (haemoglobin A1c [HbA1c] level) along with blood pressure (BP) and lipid profile (LP) during DMTAC appointments. METHOD This study retrospectively reviewed all recorded baseline and completed DMTAC data, including HbA1c level, LP and BP, of 318 eligible participants from 29 DMTACs across Perak. The participants were divided into shorter appointment interval (SAI) (≤30 days) and longer appointment interval (LAI) groups. RESULTS The majority of the baseline socio-demographic and clinical characteristics did not significantly differ between the SAI and LAI groups (p>0.05). Ischaemic heart disease (Odds ratio, OR=3.457; 95% CI= 1.354-8.826; p=0.009) and hypertension (OR=0.521; 95% CI=0.276-0.992; p=0.044) were significantly associated with the appointment intervals. Upon completion of eight DMTAC visits, the HbA1c and FBS levels and DBP significantly improved (p<0.05). However, the mean HbA1c level (1.35±2.18% vs 0.87±2.11%, p=0.548), FBS level (1.25±4.82mmol/L vs 2.29±6.23mmol/L, p=0.538), SBP (3.28±21.82mmHg vs 3.65±18.35mmHg, p=0.343) and LDL level (0.09±0.98mmol/L vs 0.07±1.13mmol/L, p=0.246) did not significantly differ between the SAI and LAI groups. CONCLUSION Longer DMTAC appointment intervals had similar improvement in glycaemic controls, blood pressure and lipid profiles as compared to shorter appointment intervals. A longer interval can be scheduled for lower-risk patients to optimise the use of human resources and minimise costs.
Collapse
Affiliation(s)
- Ying Shan Beh
- B.Pharm (Hons.) USM, Klinik Kesihatan Greentown, Jalan Raja Musa Aziz, Ipoh, Perak, Malaysia.
| | - Keshamalini Gopalsamy
- B.Pharm (Hons.) (USM), Klinik Kesihatan Jalan Oya, Jalan Oya, Sibu, Sarawak, Malaysia
| | - Sabrina Lai Fong Lee
- B.Pharm (Hons.) (USM), Klinik Kesihatan Greentown, Jalan Raja Musa Aziz, Ipoh, Perak, Malaysia
| | - V Paranthaman P Vengadasalam
- MBBS (Malaya), M.Med (Family Medicine) Malaya Klinik Kesihatan Greentown, Jalan Raja Musa Aziz, Ipoh, Perak, Malaysia
| |
Collapse
|
6
|
Tekin Z, Saygili M. The Association Between Medicaid Expansion and Diabetic Ketoacidosis Hospitalizations. Cureus 2022; 14:e30631. [PMID: 36426322 PMCID: PMC9682969 DOI: 10.7759/cureus.30631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 06/16/2023] Open
Abstract
Background and objective Diabetic ketoacidosis (DKA) is a potentially fatal complication of uncontrolled diabetes and remains a significant source of morbidity and mortality even though it is considered preventable. Diabetes is a chronic illness that requires constant monitoring and regular check-ups. Delaying or foregoing necessary diabetes care due to a lack of health insurance can result in severe complications. The Affordable Care Act (ACA) Medicaid expansion is intended to increase access to healthcare and improve health outcomes. This study aimed to examine the relationship between the ACA Medicaid expansion and hospitalizations with DKA. Methods This retrospective cross-sectional study used discharge records from 2010 to 2017 for hospitals in Texarkana, located on the border of Texas and Arkansas. The study employed a difference-in-differences method. Patients from Arkansas, which expanded Medicaid in 2014, constituted the treatment group, while those from Texas, which did not adopt the expansion, were the control group. A triple difference methodology was used to compare the impact of the expansion on patients with different socioeconomic backgrounds. The main outcome measure was DKA per 1000 discharges. Results A total of 89,184 inpatient discharges from Texarkana hospitals were analyzed; 43,286 patients were from Arkansas (48.54%) and 45,898 (51.46%) were from Texas. Even though DKA cases increased from pre-expansion (2010-2013) to post-expansion (2014-2017) period among patients from Arkansas (by a mean of 4.33) and Texas (by a mean of 8.28), the increase was milder among Arkansas patients with an adjusted decrease of 4.17 per 1000 discharges (95% CI: -5.04 to -3.31; p<0.001), implying a 42% lower risk of hospitalizations with DKA compared to the baseline averages. The triple difference analysis suggested that the decrease in incidences was more pronounced for patients from low-income areas with an adjusted decrease of 13.47 per 1000 discharges (95% CI: -22.45 to -4.49; p=0.003). Conclusions Based on our findings, Medicaid expansion decreases hospitalizations with DKA, presumably due to better monitoring and care of diabetes made possible by increasing access to healthcare among individuals with low incomes.
Collapse
Affiliation(s)
- Zehra Tekin
- Endocrinology, Diabetes and Metabolism, Christus Trinity Clinic, Tyler, USA
| | - Meryem Saygili
- Social Sciences/Economics, The University of Texas at Tyler, Tyler, USA
| |
Collapse
|
7
|
Effectiveness of Therapeutic Patient Education Interventions in Obesity and Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2022; 14:nu14183807. [PMID: 36145181 PMCID: PMC9503927 DOI: 10.3390/nu14183807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Diabetes mellitus (DM) and obesity account for the highest burden of non-communicable diseases. There is increasing evidence showing therapeutic patient education (TPE) as a clinically and cost-effective solution to improve biomedical and psychosocial outcomes among people with DM and obesity. The present systematic review and meta-analysis present a critical synthesis of the development of TPE interventions for DM and obesity and the efficacy of these interventions across a range of biomedical, psychosocial and psychological outcomes. A total of 54 of these RCTs were identified among patients with obesity and diabetes and were thus qualitatively synthesized. Out of these, 47 were included in the quantitative synthesis. There was substantial heterogeneity in the reporting of these outcomes (I2 = 88.35%, Q = 317.64), with a significant improvement noted in serum HbA1c levels (standardized mean difference (SMD) = 0.272, 95% CI: 0.118 to 0.525, n = 7360) and body weight (SMD = 0.526, 95% CI: 0.205 to 0.846, n = 1082) in the intervention group. The effect sizes were comparable across interventions delivered by different modes and delivery agents. These interventions can be delivered by allied health staff, doctors or electronically as self-help programs, with similar effectiveness (p < 0.001). These interventions should be implemented in healthcare and community settings to improve the health outcomes in patients suffering from obesity and DM.
Collapse
|
8
|
Levitz C, Jones M, Nudelman J, Cox M, Camacho D, Wielunski A, Rothman M, Tomlin J, Jaffe M. Reducing Cardiovascular Risk for Patients With Diabetes: An Evidence-Based, Population Health Management Program. J Healthc Qual 2022; 44:103-112. [PMID: 34700325 PMCID: PMC8887839 DOI: 10.1097/jhq.0000000000000332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Those with diabetes are at an increased risk of cardiovascular disease (CVD). Safety net clinics serve populations that bear a significant burden of disease and disparities and are a key setting in which to focus on reducing CVD. An integrated health system provided funding and technical assistance (TA) to safety net organizations (community health centers and public hospitals) in Northern California to decrease the risk of cardiovascular events for patients with diabetes. This was a program called Preventing Heart Attacks and Strokes Everyday (PHASE), which combined an evidence-based medication protocol with population health management and team-based care strategies. The TA supported organizations by sharing best practices, providing quality improvement coaching, and facilitating peer learning. A mixed-methods evaluation found that organizations involved in PHASE improved rates of blood pressure control and cardioprotective medication prescriptions for patients with diabetes. They made progress on these measures through strategies such as leveraging team-based care, providing education on evidence-based protocols, and using data to drive improvements. The evaluation concluded that financially supporting and providing focused TA to safety net organizations can help them build capacity and leverage their strengths to improve outcomes and potentially decrease the risk of heart attacks and strokes in communities.
Collapse
|
9
|
Group Medical Care: A Systematic Review of Health Service Performance. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182312726. [PMID: 34886452 PMCID: PMC8657170 DOI: 10.3390/ijerph182312726] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/30/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022]
Abstract
Group care models, in which patients with similar health conditions receive medical services in a shared appointment, have increasingly been adopted in a variety of health care settings. Applying the Triple Aim framework, we examined the potential of group medical care to optimize health system performance through improved patient experience, better health outcomes, and the reduced cost of health care. A systematic review of English language articles was conducted using the Cochrane Controlled Trials Register (CENTRAL), MEDLINE/PubMed, Scopus, and Embase. Studies based on data from randomized control trials (RCTs) conducted in the US and analyzed using an intent-to-treat approach to test the effect of group visits versus standard individual care on at least one Triple Aim domain were included. Thirty-one studies met the inclusion criteria. These studies focused on pregnancy (n = 9), diabetes (n = 15), and other chronic health conditions (n = 7). Compared with individual care, group visits have the potential to improve patient experience, health outcomes, and costs for a diversity of health conditions. Although findings varied between studies, no adverse effects were associated with group health care delivery in these randomized controlled trials. Group care models may contribute to quality improvements, better health outcomes, and lower costs for select health conditions.
Collapse
|
10
|
Vasireddy D, Sehgal M, Amritphale A. Risk Factors, Trends, and Preventive Measures for 30-Day Unplanned Diabetic Ketoacidosis Readmissions in the Pediatric Population. Cureus 2021; 13:e19205. [PMID: 34873537 PMCID: PMC8638216 DOI: 10.7759/cureus.19205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 11/11/2022] Open
Abstract
Background There has been a steady rise in types 1 and 2 diabetes mellitus among the youth in the USA from 2001 to 2017. Diabetic ketoacidosis (DKA) is a common and preventable presentation of both types of diabetes mellitus. According to the Centers for Disease Control and Prevention's (CDC) United States Diabetes Surveillance System, during 2004-2019 an increase in DKA hospitalization rates by 59.4% was noted, with people aged less than 45 years having the highest rates. Readmissions reflect the quality of disease management, which is integrally tied to care coordination and communication with the patient and their families. This study analyzes the trends and risk factors contributing to 30-day unplanned DKA readmissions in the pediatric age group and looks into possible preventive measures to decrease them. Methods A retrospective study was performed using the National Readmission Database (NRD) from January 1, 2017, to December 1, 2017. Pediatric patients aged 18 years and younger with the primary diagnosis of DKA were included using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code E10.10. All statistical analysis was performed using IBM SPSS Statistics for Windows, version 1.0.0.1327 (IBM Corp., Armonk, NY, USA). Pearson's chi-square test was used for categorical variables and Mann-Whitney U test was used for continuous variables. To independently determine the predictors of readmission within each clinical variable, multiple logistic regressions with values presented as odds ratios (OR) with 95% confidence intervals (CI) were performed. Results A weighted total of 19,519 DKA-related pediatric index admissions were identified from the 2017 NRD. Of these pediatric patients, 831 (4.3%) had 30-day DKA readmission. The median age of a child for readmission was 16 years with an interquartile range of 0 to 18 years. A sharp rise in 30-day DKA readmissions was noted for ages 16 years and over. Females in the 0-25th percentile median household income category, with Medicaid covered, large metropolitan areas with at least 1 million residents, and metropolitan teaching hospitals were found to have a statistically significant higher percentage of readmissions. The mean length of stay for those who had a DKA readmission was 2.06 days, with a standard deviation of 1.84 days. The mean hospital charges for those who had a DKA readmission were $ 20,339.70. The 30-day DKA readmission odds were seen to be increased for female patients, Medicaid-insured patients, admissions at metropolitan non-teaching hospitals, and children from 0-25th percentile median household income category. Conclusion There has not been much of a change in the trend and risk factors contributing to the 30-day unplanned DKA readmissions over the years despite the steady rise in cases of diabetes mellitus. The length of stay for those who did not get readmitted within 30 days was longer than for those who did. This could reflect more comprehensive care and discharge planning that may have prevented them from readmission. Diabetes mellitus is a chronic disease that demands a team effort from the patient, family, healthcare personnel, insurance companies, and lawmakers. There is scope for a lot of improvement with the way our patients are being managed, and a more holistic approach needs to be devised.
Collapse
Affiliation(s)
| | - Mukul Sehgal
- Critical Care Medicine, University of South Alabama, Mobile, USA
| | - Amod Amritphale
- Medicine/Cardiovascular Disease, University of South Alabama College of Medicine, Mobile, USA
| |
Collapse
|
11
|
Determinants of Diabetes Disease Management, 2011-2019. Healthcare (Basel) 2021; 9:healthcare9080944. [PMID: 34442081 PMCID: PMC8393363 DOI: 10.3390/healthcare9080944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/17/2021] [Accepted: 07/21/2021] [Indexed: 11/25/2022] Open
Abstract
This study estimated the effects of Medicaid Expansion, demographics, socioeconomic status (SES), and health status on disease management of diabetes over time. The hypothesis was that the introduction of the ACA and particularly Medicaid Expansion would increase the following dependent variables (all proportions): (1) provider checks of HbA1c, (2) provider checks of feet, (3) provider checks of eyes, (4) patient education, (5) annual physician checks for diabetes, (6) patient self-checks of blood sugar. Data were available from the Behavioral Risk Factor Surveillance System for 2011 to 2019. We filtered the data to include only patients with diagnosed non-gestational diabetes of age 45 or older (n = 510,991 cases prior to weighting). Linear splines modeled Medicaid Expansion based on state of residence as well as implementation status. Descriptive time series plots showed no major changes in proportions of the dependent variables over time. Quasibinomial analysis showed that implementation of Medicaid Expansion had a statistically negative effect on patient self-checks of blood sugar (odds ratio = 0.971, p < 0.001), a statistically positive effect on physician checks of HbA1c (odds ratio = 1.048, p < 0.001), a statistically positive effect on feet checks (odds ratio = 1.021, p < 0.001), and no other significant effects. Evidence of demographic, SES, and health status disparities existed for most of the dependent variables. This finding was especially significant for HbA1c checks by providers. Barriers to achieving better diabetic care remain and require innovative policy interventions.
Collapse
|
12
|
Liu CS, Feasel AL, Kline GA, Billington EO. Pharmacotherapy decisions among postmenopausal women attending a group medical consultation or a one-on-one specialist consultation at an osteoporosis center: an observational cohort study. Osteoporos Int 2021; 32:1421-1427. [PMID: 33462652 DOI: 10.1007/s00198-021-05823-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/04/2021] [Indexed: 12/21/2022]
Abstract
UNLABELLED Group medical visits for osteoporosis can improve access to care while being highly accepted by patients. In this study, a similar proportion of women planned to initiate pharmacotherapy after attending a group or traditional one-on-one osteoporosis consultation, indicating that the group consultation model does not produce unexpected treatment decisions. INTRODUCTION Group medical consultations for osteoporosis are time-efficient and highly accepted by patients, but effects on treatment decisions are unknown. We aimed to compare women's decisions to initiate or decline osteoporosis pharmacotherapy after attending either a group or transitional one-on-one osteoporosis consultation. METHODS In this observational study, we prospectively evaluated postmenopausal women referred to an osteoporosis clinic who attended a group medical visit and compared their decisions regarding pharmacologic osteoporosis treatment with retrospective data from a cohort of women who attended a traditional consultation. Both consultation types involved interaction with a specialist physician, individualized fracture risk estimation (using FRAX®), and education regarding fracture consequences and available osteoporosis medications. Both forms of consultation emphasized shared decision-making; however, group consultation attendees did not receive personalized treatment recommendations from the physician. RESULTS We reviewed the records of 125 women (median age 63 years) who attended a group consultation and 83 women (median age 64 years) who attended a traditional consultation between 2016 and 2019. Twenty-four (19%) of the group cohort and 16 (19%) of the traditional cohort were at high 10-year risk of major osteoporotic fracture (FRAX® ≥ 20.0%). A similar proportion planned to initiate pharmacologic therapy after the group and traditional consultations (23% vs 16%, p = 0.22); these proportions were comparable among women at high risk (42% vs 50%, p = 0.75) and moderate risk (19% vs 15%, p = 0.77), but a higher proportion of low-risk women planned to initiate therapy after the group consultation (18% vs 0%, p = 0.009). CONCLUSION Patient decisions to initiate pharmacologic treatment made during a group visit are similar to those made during traditional one-on-one consultation. The group consultation model represents an alternative to one-on-one assessment for delivering osteoporosis consultative services.
Collapse
Affiliation(s)
- C S Liu
- Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - A L Feasel
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada
| | - G A Kline
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - E O Billington
- Dr. David Hanley Osteoporosis Centre, Alberta Health Services, Richmond Road Diagnostic & Treatment Centre, Calgary, Alberta, Canada.
- Division of Endocrinology & Metabolism, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| |
Collapse
|
13
|
Lesser LI, Behal R. Change in Glycemic Control for Patients Enrolled in a Membership-Based Primary Care Program: Longitudinal Observational Study. JMIR Diabetes 2021; 6:e27453. [PMID: 33999830 PMCID: PMC8235285 DOI: 10.2196/27453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/19/2021] [Accepted: 05/13/2021] [Indexed: 01/23/2023] Open
Abstract
Background Both primary care practices based on the chronic care model (CCM) and digital therapeutics have been shown to improve the care of patients with diabetes. Objective The aim of this observational study was to examine the change in diabetes control for patients enrolled in a membership-based primary care service that is based on the CCM. Methods Using a diabetes registry, we analyzed the change in glycated hemoglobin (HbA1c) for patients with uncontrolled diabetes mellitus (initial HbA1c≥9%). All patients had access to a technology-enhanced primary care practice built on the CCM. Results The registry included 621 patients diagnosed with uncontrolled diabetes. All patients had at least two HbA1c measurements, with the average time between the first and last measurement of 1.2 years (SD 0.4). The average starting value of HbA1c was 10.7, which decreased to 8.7, corresponding to a reduction of 2.03 (P<.001). Secondary analyses showed statistically significant reductions in total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides. Conclusions Patients with initially uncontrolled diabetes who undergo care in a technology-enhanced primary care practice based on the CCM have long-term clinically meaningful reductions in HbA1c.
Collapse
Affiliation(s)
| | - Raj Behal
- One Medical, San Francisco, CA, United States
| |
Collapse
|
14
|
Dovel K, Phiri K, Mphande M, Mindry D, Sanudi E, Bellos M, Hoffman RM. Optimizing Test and Treat in Malawi: health care worker perspectives on barriers and facilitators to ART initiation among HIV-infected clients who feel healthy. Glob Health Action 2020; 13:1728830. [PMID: 32098595 PMCID: PMC7054923 DOI: 10.1080/16549716.2020.1728830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Test and Treat has been widely adopted throughout sub-Saharan Africa, whereby all HIV-positive individuals initiate antiretroviral therapy (ART) immediately upon diagnosis and continue for life. However, clients who feel healthy may delay ART initiation, despite being eligible under new treatment guidelines. Objective: We examined health care worker (HCW) perceptions and experiences on how feeling healthy positively or negatively influences treatment initiation among HIV-positive clients in Malawi. Methods: We conducted 12 focus group discussions with 101 HCWs across six health facilities in Central Malawi. Data were analyzed through constant comparison methods using Atlas.ti7.5. Results: Feeling healthy influences perceptions of ART initiation among HIV-positive clients. HCWs described that healthy clients feel that there are few tangible benefits to immediate ART initiation, but numerous risks. Fear of stigma and unwanted disclosure, disruption of daily activities, fear of side effects, and limited knowledge about the benefits of early initiation were perceived by HCWs to deter healthy clients from initiating ART. Conclusion: Feeling healthy may exacerbate barriers to ART initiation. Strategies to reach healthy clients are needed, such as chronic care models, differentiated models of care that minimize disruptions to daily activities, and community sensitization on the benefits of early initiation.
Collapse
Affiliation(s)
- Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA.,Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Khumbo Phiri
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Misheck Mphande
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Deborah Mindry
- UC Global Health Institute, Center for Women's Health Gender and Empowerment, Los Angeles, CA, USA
| | - Esnart Sanudi
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Mcdaphton Bellos
- Partners in Hope Medical Centre, EQUIP Innovations for Health, Lilongwe, Malawi
| | - Risa M Hoffman
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, CA, USA
| |
Collapse
|
15
|
Cheng AYY, Bajaj HS, Clement M, Sherifali D, Eisen D, Heisel O, Keown P, Richard JF. Assessing the Effect of Quality-Improvement Strategies for Organization of Care in Type 2 Diabetes Outcomes in Adults: Aim-Strait. Can J Diabetes 2020; 45:319-326.e5. [PMID: 33223422 DOI: 10.1016/j.jcjd.2020.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/20/2020] [Accepted: 09/28/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To observe the effect of an organization-of-care improvement process on the achievement of therapeutic goals for people with type 2 diabetes mellitus (T2DM). METHODS This single-arm cohort study analyzed the electronic medical records of patients with T2DM in 5 primary care practices in Ontario, Canada, before and 2 years after implementation of an individualized quality-improvement program. The primary outcome was the change in glycated hemoglobin (A1C) between baseline and follow up, with secondary analyses including change in other metabolic parameters, medication patterns and clinic visits. Prespecified subgroup analysis of patients with baseline values above guideline therapeutic targets was performed. RESULTS In the overall population of 1,886 patients, A1C improved from 7.1% (baseline) to 7.0% (follow up) (p<0.001); low-density lipoprotein-cholesterol (LDL-C) improved from 2.1 to 1.9 mmol/L (p<0.001); and diastolic blood pressure (BP) improved from 75 to 74 mmHg (p<0.001), with no significant change observed in systolic BP. Of those patients who were above guideline-recommended therapeutic targets at baseline, improvements were observed at follow-up: A1C 8.3±1.3% to 7.8±1.3% (p<0.001), LDL-C 2.9±0.7 mmol/L to 2.4±0.9 mmol/L (p<0.001), systolic BP 144±11 to 134±16 mmHg (p<0.001) and diastolic BP 80±10 to 75±11 mmHg (p<0.001), with the percentages of patients achieving target at follow up being 32% for A1C, 40% for LDL-C and 49% for systolic BP. Overall, 22% of patients achieved all 3 targets at baseline compared to 28% at follow up (p<0.001). CONCLUSIONS The implementation of an organization-of-care improvement program in primary care was associated with improved metabolic control, which was most pronounced in patients with baseline levels above guideline-recommended therapeutic targets.
Collapse
Affiliation(s)
- Alice Y Y Cheng
- Department of Medicine, University of Toronto, Trillium Health Partners and Unity Health Toronto, Toronto, Ontario, Canada.
| | | | - Maureen Clement
- Department of Family Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Diana Sherifali
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Doron Eisen
- West Durham Family Health Team, Pickering, Ontario, Canada
| | - Olaf Heisel
- Syreon Corporation, Vancouver, British Columbia, Canada
| | - Paul Keown
- Syreon Corporation, Vancouver, British Columbia, Canada; Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | |
Collapse
|
16
|
Belizan M, Alonso JP, Nejamis A, Caporale J, Copo MG, Sánchez M, Rubinstein A, Irazola V. Barriers to hypertension and diabetes management in primary health care in Argentina: qualitative research based on a behavioral economics approach. Transl Behav Med 2020; 10:741-750. [PMID: 30947329 PMCID: PMC7529038 DOI: 10.1093/tbm/ibz040] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite efforts to improve detection and treatment of adults with hypertension and diabetes in Argentina, many public healthcare system users remain undiagnosed or face barriers in managing these diseases. The purpose of this study is to identify health system, provider, and user-related factors that may hinder detection and treatment of hypertension and diabetes using a traditional and behavioral economics approach. We did qualitative research using in-depth semistructured interviews and focus groups with healthcare providers and adult users of Public Primary Care Clinics. Health system barriers included inadequate care accessibility; poor integration between primary care clinics and local hospitals; lack of resources; and gender bias and neglect of adult chronic disease. Healthcare provider-related barriers were inadequate training; lack of availability or reluctance to adopt Clinical Practice Guidelines; and lack of counseling prioritization. From a behavioral economics perspective, bottlenecks were related to inertia and a status quo, overconfidence, and optimism biases. User-related barriers for treatment adherence included lack of accurate information; resistance to adopt lifelong treatment; affordability; and medical advice mistrust. From a behavioral economics perspective, the most significant bottlenecks were overconfidence and optimism, limited attention, and present biases. Based on these findings, new interventions that aim to improve prevention and control of chronic conditions can be proposed. The study provides empirical evidence regarding the barriers and bottlenecks in managing chronic conditions in primary healthcare settings. Results may contribute to the design of behavioral interventions targeted towards healthcare provision for the affected population.
Collapse
Affiliation(s)
- Maria Belizan
- Institute for Clinical Effectiveness and Health Policy – IECS, Buenos Aires, Argentina
| | - Juan P Alonso
- Instituto de Investigaciones Gino Germani, Universidad de Buenos Aires, Buenos Aires, Argentina
- CONICET, Buenos Aires, Argentina
| | - Analía Nejamis
- Institute for Clinical Effectiveness and Health Policy – IECS, Buenos Aires, Argentina
| | - Joaquín Caporale
- Institute for Clinical Effectiveness and Health Policy – IECS, Buenos Aires, Argentina
| | - Mariano G Copo
- Physical and Mental Health Promotion Office, Ministry of National Security, Argentina
| | - Mario Sánchez
- Inter-American Development Bank, Buenos Aires, Argentina
| | - Adolfo Rubinstein
- Institute for Clinical Effectiveness and Health Policy – IECS, Buenos Aires, Argentina
| | - Vilma Irazola
- Institute for Clinical Effectiveness and Health Policy – IECS, Buenos Aires, Argentina
| |
Collapse
|
17
|
Lee J, Callaghan T, Ory M, Zhao H, Bolin JN. The Impact of Medicaid Expansion on Diabetes Management. Diabetes Care 2020; 43:1094-1101. [PMID: 31649097 PMCID: PMC7171935 DOI: 10.2337/dc19-1173] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/01/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes is a chronic health condition contributing to a substantial burden of disease. According to the Robert Wood Johnson Foundation, 10.9 million people were newly insured by Medicaid between 2013 and 2016. Considering this coverage expansion, the Affordable Care Act (ACA) could significantly affect people with diabetes in their management of the disease. This study evaluates the impact of the Medicaid expansion under the ACA on diabetes management. RESEARCH DESIGN AND METHODS This study includes 22,335 individuals with diagnosed diabetes from the 2011 to 2016 Behavioral Risk Factor Surveillance System. It uses a difference-in-differences approach to evaluate the impact of the Medicaid expansion on self-reported access to health care, self-reported diabetes management, and self-reported health status. Additionally, it performs a triple-differences analysis to compare the impact between Medicaid expansion and nonexpansion states considering diabetes rates of the states. RESULTS Significant improvements in Medicaid expansion states as compared with non-Medicaid expansion states were evident in self-reported access to health care (0.09 score; P = 0.023), diabetes management (1.91 score; P = 0.001), and health status (0.10 score; P = 0.026). Among states with large populations with diabetes, states that expanded Medicaid reported substantial improvements in these areas in comparison with those that did not expand. CONCLUSIONS The Medicaid expansion has significant positive effects on self-reported diabetes management. While states with large diabetes populations that expanded Medicaid have experienced substantial improvements in self-reported diabetes management, non-Medicaid expansion states with high diabetes rates may be facing health inequalities. The findings provide policy implications for the diabetes care community and policy makers.
Collapse
Affiliation(s)
- Jusung Lee
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX
| | - Timothy Callaghan
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX
| | - Marcia Ory
- Department of Environmental and Occupational Health, School of Public Health, Texas A&M University, College Station, TX
| | - Hongwei Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, TX
| | - Jane N Bolin
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station, TX
- College of Nursing, Texas A&M University, College Station, TX
| |
Collapse
|
18
|
Ganetsky VS, Long JA, Mitra N, Chaiyachati KH, Kaufman ST. Impact of a Multidisciplinary, Endocrinologist-Led Shared Medical Appointment Model on Diabetes-Related Outcomes in an Underserved Population. Diabetes Spectr 2020; 33:74-81. [PMID: 32116457 PMCID: PMC7026762 DOI: 10.2337/ds19-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A multidisciplinary endocrinologist-led shared medical appointment (SMA) model showed statistically significant reductions in A1C from baseline over 3 years that were not significantly different from appointments with endocrinologists or primary care providers alone within a resource-poor population. Similarly, the SMA model achieved clinical outcomes on par with endocrinologist-only visits with the added benefit of improving endocrine provider productivity and specialty access for patients. Greater patient engagement with the SMA model was associated with significantly lower A1C.
Collapse
Affiliation(s)
| | - Judith A. Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Krisda H. Chaiyachati
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Steven T. Kaufman
- Cooper University Hospital, Urban Health Institute, Camden, NJ
- Cooper Medical School of Rowan University, Camden, NJ
| |
Collapse
|
19
|
Kwan BM, Dickinson LM, Glasgow RE, Sajatovic M, Gritz M, Holtrop JS, Nease DE, Ritchie N, Nederveld A, Gurfinkel D, Waxmonsky JA. The Invested in Diabetes Study Protocol: a cluster randomized pragmatic trial comparing standardized and patient-driven diabetes shared medical appointments. Trials 2020; 21:65. [PMID: 31924249 PMCID: PMC6954498 DOI: 10.1186/s13063-019-3938-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/26/2019] [Indexed: 02/07/2023] Open
Abstract
Background Shared medical appointments (SMAs) have been shown to be an efficient and effective strategy for providing diabetes self-management education and self-management support. SMA features vary and it is not known which features are most effective for different patients and practice settings. The Invested in Diabetes study tests the comparative effectiveness of SMAs with and without multidisciplinary care teams and patient topic choice for improving patient-centered and clinical outcomes related to diabetes. Methods This study compares the effectiveness of two SMA approaches using the Targeted Training for Illness Management (TTIM) curriculum. Standardized SMAs are led by a health educator with a set order of TTIM topics. Patient-driven SMAs are delivered collaboratively by a multidisciplinary care team (health educator, medical provider, behavioral health provider, and a peer mentor); patients select the order and emphasis on TTIM topics. Invested in Diabetes is a cluster randomized pragmatic trial involving approximately 1440 adult patients with type 2 diabetes. Twenty primary care practices will be randomly assigned to either standardized or patient-driven SMAs. A mixed-methods evaluation will include quantitative (practice- and patient-level data) and qualitative (practice and patient interviews, observation) components. The primary patient-centered outcome is diabetes distress. Secondary outcomes include autonomy support, self-management behaviors, clinical outcomes, patient reach, and practice-level value and sustainability. Discussion Practice and patient stakeholder input guided protocol development for this pragmatic trial comparing SMA approaches. Implementation strategies from the enhanced Replicating Effective Programs framework will help ensure practices maintain fidelity to intervention protocols while tailoring workflows to their settings. Invested in Diabetes will contribute to the literature on chronic illness management and implementation science using the RE-AIM model. Trial registration ClinicalTrials.gov, NCT03590041. Registered on 5 July 2018.
Collapse
Affiliation(s)
- Bethany M Kwan
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA.
| | - L Miriam Dickinson
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA
| | - Russell E Glasgow
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA.,VA Eastern Colorado QUERI and Geriatric Research Centers, 1055 Clermont St, Denver, CO, 80220, USA
| | - Martha Sajatovic
- Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH, 44106, USA
| | - Mark Gritz
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA
| | - Jodi Summers Holtrop
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA
| | - Don E Nease
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA
| | - Natalie Ritchie
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA.,Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA
| | - Andrea Nederveld
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA
| | - Dennis Gurfinkel
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA
| | - Jeanette A Waxmonsky
- University of Colorado School of Medicine, 13199 E Montview Blvd Ste 210, Aurora, CO, 80045, USA.,VA Eastern Colorado QUERI and Geriatric Research Centers, 1055 Clermont St, Denver, CO, 80220, USA
| |
Collapse
|
20
|
Zupa MF, Arena VC, Johnson PA, Thearle MB, Siminerio LM. A Coordinated Population Health Approach to Diabetes Education in Primary Care. DIABETES EDUCATOR 2019; 45:580-585. [PMID: 31578931 DOI: 10.1177/0145721719879427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this feasibility study was to determine the effectiveness of an insurer-based diabetes educator (DE)-driven intervention that relies on systematic restructuring of primary care (PC) linking DE services through population health, practice redesign, and coordinated care for patients with diabetes mellitus (DM) identified as high risk. METHODS Two DEs were introduced as members of PC teams and worked with practice-based care managers (PBCMs) to identify and refer DM patients considered at high risk, A1C >9%, DM-related emergency room visit or hospitalization, or reported barriers to care. Elements shown to ensure quality, including population management, diabetes self-management education and support (DSMES), and coordinated patient-centered team-based PC, were central to intervention. A1C, low-density lipoprotein (LDL), and body mass index (BMI) were collected at baseline and outcomes were followed at 3, 6, 9, and 12 months after intervention. RESULTS For patients who received intervention, A1C decreased on average 1.2% (95% confidence interval [CI], 0.8-1.5) from 9.6% (81 mmol/mol) to 8.4% (68 mmol/mol) over 6 months and by 1.1% (95% CI, 0.7-1.5) from 9.2% (77 mmol/mol) to 8.1% (65 mmol/mol) over 12 months, indicating durable improvement in glycemic control. There was no significant change in BMI, and LDL improvement observed at 9 months was lost by 12-month follow-up. CONCLUSION Findings support the feasibility of a DE-driven intervention for patients with DM at high risk through a coordinated PC approach that improves glycemic control. The feasibility and clinical outcome of this model warrant consideration of a fresh role for DEs in the complex environment of value-based care.
Collapse
Affiliation(s)
- Margaret F Zupa
- From Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vincent C Arena
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Linda M Siminerio
- University of Pittsburgh Diabetes Institute, Pittsburgh, Pennsylvania
| |
Collapse
|
21
|
Mirhoseiny S, Geelvink T, Martin S, Vollmar HC, Stock S, Redaelli M. Does task delegation to non-physician health professionals improve quality of diabetes care? Results of a scoping review. PLoS One 2019; 14:e0223159. [PMID: 31603900 PMCID: PMC6788697 DOI: 10.1371/journal.pone.0223159] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective As a result of unhealthy lifestyles, reduced numbers of healthcare providers are having to deal with an increasing number of diabetes patients. In light of this shortage of physicians and nursing staff, new concepts of care are needed. The aim of this scoping review is to review the literature and examine the effects of task delegation to non-physician health professionals, with a further emphasis on inter-professional care. Research design and methods Systematic searches were performed using the PubMed, Embase and Google Scholar databases to retrieve papers published between January 1994 and December 2017. Randomised/non-randomised controlled trials and studies with a before/after design that described the delegation of tasks from physicians to non-physicians in diabetes care were included in the search. This review is a subgroup analysis that further assesses all the studies conducted using a team-based approach. Results A total of 45 studies with 12,092 patients met the inclusion criteria. Most of the interventions were performed in an outpatient setting with type-2 diabetes mellitus patients. The non-physician healthcare professionals involved in the team were nurses, pharmacists, community health workers and dietitians. Most studies showed significant improvements in glycaemic control and high patient satisfaction, while there were no indications that the task delegation affected quality of life scores. Conclusions The findings of the review suggest that task delegation can provide equivalent glycaemic control and potentially lead to an improvement in the quality of care. However, this review revealed a lack of clinical endpoints, as well as an inconsistency between the biochemical outcome parameters and the patient-centred outcome parameters. Given the vast differences between the individual healthcare systems used around the world, further high-quality research with an emphasis on long-term outcome effects and the expertise of non-physicians is needed.
Collapse
Affiliation(s)
- Sanas Mirhoseiny
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Tjarko Geelvink
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Stephan Martin
- Faculty of Medicine, University of Düsseldorf, Düsseldorf, Germany
- West-German Center of Diabetes and Health, Düsseldorf Catholic Hospital Group, Düsseldorf, Germany
| | - Horst Christian Vollmar
- Department of General Practice, Faculty of Medicine, Ruhr-Universität Bochum, Gebäude MAFO 1/61, Bochum, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Marcus Redaelli
- Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
- Institute of General Practice and Family Medicine, Faculty of Health, Witten/Herdecke University, Witten, Germany
- * E-mail:
| |
Collapse
|
22
|
Mogre V, Johnson NA, Tzelepis F, Paul C. Attitudes towards, facilitators and barriers to the provision of diabetes self-care support: A qualitative study among healthcare providers in Ghana. Diabetes Metab Syndr 2019; 13:1745-1751. [PMID: 31235088 DOI: 10.1016/j.dsx.2019.03.041] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022]
Abstract
STATEMENT OF THE PROBLEM Self-care support provided by healthcare providers (HCPs) is critical to diabetes self-care. However, a number of barriers prevent HCPs from providing self-care support to people with diabetes. We explored attitudes towards, barriers and facilitators of the provision of diabetes self-care support among Ghanaian HCPs. METHODS Fourteen semi-structured interviews were conducted among HCPs recruited from three diabetes clinics in Tamale, Ghana. All interviews were digitally recorded and transcribed verbatim. Transcripts were coded and analysed thematically. RESULTS HCPs reported a sense of responsibility and urgency to provide self-care education to diabetes patients; while believing it was the patients' responsibility to self-care for their diabetes condition. Accordingly, HCPs perceived their role to be limited to information sharing rather than behaviour change interventions. Facilitators to the provision of self-care support included patients' motivation, and team work among healthcare professionals. Barriers that hindered self-care support included language barriers and poor inter-professional collaboration. Furthermore, HCPs discussed that they felt inadequately trained to provide self-care support. Healthcare-system-related barriers were inadequate office space, lack of professional development programmes, high patient numbers, inadequate staff numbers, inadequate health insurance and a lack of sufficient supplies and equipment in the hospital. CONCLUSION HCPs attitudes were generally favourable towards supporting self-care, albeit with a focus on information provision rather than behaviour change. Training in effective strategies for providing self-care support are needed, and better use of the resources that are available.
Collapse
Affiliation(s)
- Victor Mogre
- Department of Health Professions Education and Innovative Learning, School of Medicine and Health Sciences, University for Development Studies, Tamale, Ghana; School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia.
| | - Natalie A Johnson
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia; Hunter Medical Research Institute, Locked Bag 1000, New Lambton, New South Wales, 2305, Australia
| | - Flora Tzelepis
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia; Hunter Medical Research Institute, Locked Bag 1000, New Lambton, New South Wales, 2305, Australia; Hunter New England Population Health, Hunter New England Local Health District, Locked Mail Bag 10, Wallsend, New South Wales, 2287, Australia
| | - Christine Paul
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, New South Wales, 2308, Australia; Hunter Medical Research Institute, Locked Bag 1000, New Lambton, New South Wales, 2305, Australia
| |
Collapse
|
23
|
Lawrenson JG, Graham-Rowe E, Lorencatto F, Rice S, Bunce C, Francis JJ, Burr JM, Aluko P, Vale L, Peto T, Presseau J, Ivers NM, Grimshaw JM. What works to increase attendance for diabetic retinopathy screening? An evidence synthesis and economic analysis. Health Technol Assess 2019; 22:1-160. [PMID: 29855423 DOI: 10.3310/hta22290] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetic retinopathy screening (DRS) is effective but uptake is suboptimal. OBJECTIVES To determine the effectiveness of quality improvement (QI) interventions for DRS attendance; describe the interventions in terms of QI components and behaviour change techniques (BCTs); identify theoretical determinants of attendance; investigate coherence between BCTs identified in interventions and determinants of attendance; and determine the cost-effectiveness of QI components and BCTs for improving DRS. DATA SOURCES AND REVIEW METHODS Phase 1 - systematic review of randomised controlled trials (RCTs) evaluating interventions to increase DRS attendance (The Cochrane Library, MEDLINE, EMBASE and trials registers to February 2017) and coding intervention content to classify QI components and BCTs. Phase 2 - review of studies reporting factors influencing attendance, coded to theoretical domains (MEDLINE, EMBASE, PsycINFO and sources of grey literature to March 2016). Phase 3 - mapping BCTs (phase 1) to theoretical domains (phase 2) and an economic evaluation to determine the cost-effectiveness of BCTs or QI components. RESULTS Phase 1 - 7277 studies were screened, of which 66 RCTs were included in the review. Interventions were multifaceted and targeted patients, health-care professionals (HCPs) or health-care systems. Overall, interventions increased DRS attendance by 12% [risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14] compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted and general QI interventions were effective, particularly when baseline attendance levels were low. All commonly used QI components and BCTs were associated with significant improvements, particularly in those with poor attendance. Higher effect estimates were observed in subgroup analyses for the BCTs of 'goal setting (outcome, i.e. consequences)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes (consequences) of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients and of 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting HCPs. Phase 2 - 3457 studies were screened, of which 65 non-randomised studies were included in the review. The following theoretical domains were likely to influence attendance: 'environmental context and resources', 'social influences', 'knowledge', 'memory, attention and decision processes', 'beliefs about consequences' and 'emotions'. Phase 3 - mapping identified that interventions included BCTs targeting important barriers to/enablers of DRS attendance. However, BCTs targeting emotional factors around DRS were under-represented. QI components were unlikely to be cost-effective whereas BCTs with a high probability (≥ 0.975) of being cost-effective at a societal willingness-to-pay threshold of £20,000 per QALY included 'goal-setting (outcome)', 'feedback on outcomes of behaviour', 'social support' and 'information about health consequences'. Cost-effectiveness increased when DRS attendance was lower and with longer screening intervals. LIMITATIONS Quality improvement/BCT coding was dependent on descriptions of intervention content in primary sources; methods for the identification of coherence of BCTs require improvement. CONCLUSIONS Randomised controlled trial evidence indicates that QI interventions incorporating specific BCT components are associated with meaningful improvements in DRS attendance compared with usual care. Interventions generally used appropriate BCTs that target important barriers to screening attendance, with a high probability of being cost-effective. Research is needed to optimise BCTs or BCT combinations that seek to improve DRS attendance at an acceptable cost. BCTs targeting emotional factors represent a missed opportunity to improve attendance and should be tested in future studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42016044157 and PROSPERO CRD42016032990. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- John G Lawrenson
- Centre for Applied Vision Research, School of Health Sciences, City, University of London,London,UK
| | - Ella Graham-Rowe
- Centre for Health Services Research, School of Health Sciences, City, University of London,London,UK
| | - Fabiana Lorencatto
- Centre for Health Services Research, School of Health Sciences, City, University of London,London,UK
| | - Stephen Rice
- Health Economics Group, Institute of Health and Society, Newcastle University,Newcastle upon Tyne,UK
| | - Catey Bunce
- Department of Primary Care & Public Health Sciences, King's College London,London,UK
| | - Jill J Francis
- Centre for Health Services Research, School of Health Sciences, City, University of London,London,UK
| | | | - Patricia Aluko
- Health Economics Group, Institute of Health and Society, Newcastle University,Newcastle upon Tyne,UK
| | - Luke Vale
- Health Economics Group, Institute of Health and Society, Newcastle University,Newcastle upon Tyne,UK
| | - Tunde Peto
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast,Belfast,UK
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute,Ottawa, ON,Canada.,School of Epidemiology, Public Health, and Preventive Medicine, University of Ottawa,Ottawa, ON,Canada
| | - Noah M Ivers
- Department of Family and Community Medicine, Women's College Hospital - University of Toronto,Toronto, ON,Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute,Ottawa, ON,Canada.,Department of Medicine, University of Ottawa,Ottawa, ON,Canada
| |
Collapse
|
24
|
Morgan SA, Ali MM, Channon AA, Al-Sabahi S, Al Suwaidi H, Osman N, Al Salameen M, Khoja T. Prevalence and correlates of diabetes and its comorbidities in four Gulf Cooperation Council countries: evidence from the World Health Survey Plus. J Epidemiol Community Health 2019; 73:630-636. [PMID: 30894421 DOI: 10.1136/jech-2018-211187] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 01/31/2019] [Accepted: 02/19/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Gulf Cooperation Council countries are witnessing unprecedented changes due to fast economic development and population growth. The aims of this study were twofold: first, to estimate the prevalence of diabetes and its comorbidities; second, to examine the association of sociodemographic risk factors and healthcare service utilisation with diabetes. METHODS Data from the World Health Survey Plus (WHS+) from Kuwait, Oman, Saudi Arabia and the United Arab Emirates were used. The WHS+ is a nationally representative household survey of the adult population, conducted between 2008 and 2009. Both logistic regression and zero-inflated Poisson models were applied to examine the associations of risk factors, comorbidity and treatment with self-reported diabetes. RESULTS The highest level of diabetes was observed in Kuwait, with 40.8% among the oldest age group. High body mass index, older age and low education were all associated with diabetes in all settings. High levels of comorbidity existed within the diabetic population. Over 50% of diabetics in all countries reported having at least one chronic condition. In Kuwait and Saudi Arabia, one in five diabetics reported having two or more comorbidities. Treatment prevalence was above 80% across all sociodemographic categories. CONCLUSION The burden of diabetes, although high, is not uniform across populations in the four Gulf countries. Differential exposure to risk, such as unhealthy lifestyles, may be creating a disadvantage for certain populations and influencing the co-occurrence of chronic conditions. In response, a multifaceted and patient-centred approach is needed at all levels of healthcare to control and prevent non-communicable diseases.
Collapse
Affiliation(s)
- Sara Afshar Morgan
- Primary Care and Population Health, University of Southampton, Southampton, UK
| | - Mohamed Mahmoud Ali
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Andrew Amos Channon
- Department of Social Statistics and Demography, University of Southampton, Southampton, UK
| | | | - Huda Al Suwaidi
- Vulnerable Group Department, Community Development Authority, Dubai, United Arab Emirates
| | - Nabil Osman
- General Director for Health Statistics and Information, Ministry of Health, Riyadh, Saudi Arabia
| | - Mostafa Al Salameen
- Department of Health Registration, National Center of Health Information, Ministry of Health, Kuwait City, State of Kuwait, Kuwait
| | - Tawfik Khoja
- Department of Primary Care & Public Health, School of Public Health, Imperial College, London, UK
| |
Collapse
|
25
|
Cheng T, D'Amico S, Luo M, Lestoquoy AS, Yinusa-Nyahkoon L, Laird LD, Gardiner PM. Health Disparities in Access to Nonpharmacologic Therapies in an Urban Community. J Altern Complement Med 2019; 25:48-60. [PMID: 30234363 DOI: 10.1089/acm.2018.0217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The overuse of prescription opioids for chronic pain is recognized as a public health crisis. Yet, poor access to nonpharmacologic treatments is the norm in low-income, racially and ethnically diverse patients with chronic pain. The main objective of this study was to understand how chronic pain impacts low-income individuals with chronic pain and their communities from multiple perspectives. DESIGN This was a qualitative study using a Science Café methodology. SETTING The Science Café event was held at an urban community center in Boston, MA. SUBJECTS Inclusion criteria included the following: having the ability to attend the event, being at least 18 years of age or older, and participating in English. METHODS Data were collected through self-reported questionnaires and audio or video recordings of two focus groups. Quantitative and qualitative data were analyzed with SAS 9.3 and NVivo 10. RESULTS Thirty participants attended the Science Café event. The average age was 45 years, 77% reported as female, 42% identified as black, and 19% as Hispanic. Participants identified themselves as either patients (46%) or providers (54%) to the chronic pain community. Our forum revealed three major themes: (1) nonpharmacologic options for chronic pain management are warranted, (2) larger sociodemographic and contextual factors influence management of chronic pain, and (3) both patients and providers value the patient-provider relationship and acknowledge the need for better communication for patients with chronic pain. CONCLUSIONS Future research should consider identifying and addressing disparities in access to nonpharmacologic treatments for chronic pain in relation to underlying social determinants of health, particularly for racially and ethnically diverse patients.
Collapse
Affiliation(s)
- Teresa Cheng
- 1 Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Salvatore D'Amico
- 1 Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Man Luo
- 1 Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Anna Sophia Lestoquoy
- 1 Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Leanne Yinusa-Nyahkoon
- 1 Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Lance D Laird
- 1 Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Paula M Gardiner
- 1 Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
- 2 Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts
| |
Collapse
|
26
|
Kong JX, Zhu L, Wang HM, Li Y, Guo AY, Gao C, Miao YY, Wang T, Lu XY, Zhu HH, Patrick DL. Effectiveness of the Chronic Care Model in Type 2 Diabetes Management in a Community Health Service Center in China: A Group Randomized Experimental Study. J Diabetes Res 2019; 2019:6516581. [PMID: 30719455 PMCID: PMC6335771 DOI: 10.1155/2019/6516581] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/17/2018] [Accepted: 11/20/2018] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The Chronic Care Model, based on core elements of team-centered care in chronic diseases, has widely been accepted. This study was aimed at evaluating the effectiveness of the Chronic Care Model in type 2 diabetes management. METHODS A group randomized experimental study was conducted. Twelve communities of the Zhaohui Community Health Service Center in Hangzhou, China, were randomly assigned into an intervention group (n = 6) receiving the Chronic Care Model-based intervention and a control group (n = 6) receiving conventional care. A total of three hundred patients, twenty-five for each community, aged ≥18 years with type 2 diabetes for at least 1-year duration, were recruited. Data of health behaviors, clinical outcomes, and health-related quality of life (Short-Form 36-item questionnaire) were collected before and after a 9-month intervention and analyzed using descriptive statistics, t-test, chi-square test, binary logistic regression, and linear mixed regression. A total of 258 patients (134 in intervention and 124 in control) who completed the baseline and follow-up evaluations and the entire intervention were included in the final analyses. RESULTS Health behaviors such as drinking habit (OR = 0.07, 95% CI: 0.01, 0.75), physical activity (OR = 2.92, 95% CI: 1.18, 7.25), and diet habit (OR = 4.30, 95% CI: 1.49, 12.43) were improved. The intervention group had a remarkable reduction in glycated hemoglobin (from 7.17% to 6.60%, P < 0.001). The quality of life score changes of the role limitation due to physical problems (mean = 9.97, 95% CI: 3.33, 16.60), social functioning (mean = 6.50, 95% CI: 2.37, 10.64), role limitation due to emotional problems (mean = 8.06, 95% CI: 2.15, 13.96), and physical component summary score (mean = 3.31, 95% CI: 1.22, 5.39) were improved in the intervention group compared to the control group. CONCLUSION The Chronic Care Model-based intervention helped improve some health behaviors, clinical outcomes, and quality of life of type 2 diabetes patients in China in a short term.
Collapse
Affiliation(s)
- Jing-Xia Kong
- Department of Social Medicine and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
- Department of Investment and Insurance, Zhejiang Financial College, Hangzhou, Zhejiang Province, China
| | - Lin Zhu
- Department of Social Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Hong-Mei Wang
- Department of Social Medicine and Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Ying Li
- Department of Social Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - An-Ying Guo
- Department of Social Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Chao Gao
- Department of Social Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yan-Yao Miao
- Department of Social Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Ting Wang
- Department of Social Medicine, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xiao-Yang Lu
- Department of Pharmacy of the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Hong-Hong Zhu
- Preventive Medicine Institute, Louisiana, MO 63353, USA
| | - Donald L. Patrick
- Department of Health Services, University of Washington, H670 Health Sciences Building, Box 357660, Seattle, WA 98195-7660, USA
| |
Collapse
|
27
|
Vaughan EM, Johnston CA, Arlinghaus KR, Hyman DJ, Foreyt JP. A Narrative Review of Diabetes Group Visits in Low-Income and Underserved Settings. Curr Diabetes Rev 2019; 15:372-381. [PMID: 30421682 PMCID: PMC6511502 DOI: 10.2174/1573399814666181112145910] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 11/05/2018] [Accepted: 11/07/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Prior studies have supported the efficacy of diabetes group visits. However, the benefit of diabetes group visits for low-income and underserved individuals is not clear. The purpose of this study was to conduct a narrative review in order to clarify the efficacy of diabetes group visits in low-income and underserved settings. METHODS The authors performed a narrative review, categorizing studies into nonrandomized and randomized. RESULTS A total of 14 studies were identified. Hemoglobin A1c was the most commonly measured outcome, which improved for the majority of group visit participants. Preventive care showed consistent improvement for intervention arms. There were several other study outcomes including metabolic (i.e., blood pressure), behavioral (i.e., exercise), functional (i.e., quality of life), and system-based (i.e., cost). CONCLUSION Diabetes group visits for low-income and underserved individuals resulted in superior preventive care but the impact on glycemic control remains unclear.
Collapse
Affiliation(s)
- Elizabeth M. Vaughan
- Department of Medicine, Baylor College of Medicine, 1504 Taub Loop, 2 RM-81-001 a-f. BCM 285, Houston, TX, USA. 1-713-873-3560
| | - Craig A. Johnston
- Department of Health & Human Performance, University of Houston, 3855 Holman Street, Houston, TX, USA. 1-713-743-0613
| | - Katherine R. Arlinghaus
- Department of Health & Human Performance, University of Houston, 3855 Holman Street, Houston, TX, USA. 1-713-743-0613
| | - David J. Hyman
- Department of Medicine, Baylor College of Medicine, 1504 Taub Loop, 2 RM-81-001 a-f. BCM 285, Houston, TX, USA. 1-713-873-3560
| | - John P. Foreyt
- Department of Medicine, Baylor College of Medicine, 1504 Taub Loop, 2 RM-81-001 a-f. BCM 285, Houston, TX, USA. 1-713-873-3560
| |
Collapse
|
28
|
Kutz TL, Roszhart JM, Hale M, Dolan V, Suchomski G, Jaeger C. Improving comprehensive care for patients with diabetes. BMJ Open Qual 2018; 7:e000101. [PMID: 30397656 PMCID: PMC6202994 DOI: 10.1136/bmjoq-2017-000101] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/20/2018] [Accepted: 09/27/2018] [Indexed: 12/15/2022] Open
Abstract
Patients with diabetes require access to systematic and ongoing care delivered by a team of healthcare providers. Despite national attention and well-accepted best practices, diabetic care, blood pressure and haemoglobin A1c (A1c) levels for patients with diabetes in our primary care setting were highly variable and below the Healthcare Effectiveness Data and Information Set (HEDIS) 75th percentile benchmark. From January 2015 to January 2016, 22% of patients with diabetes in our primary care setting had both blood pressure and A1c levels controlled and 23% had their annual diabetic care bundle completed, which includes A1c and blood pressure measurements, foot examination and nephropathy attention. Lack of standardised care algorithms, electronic health record documentation and education was identified. Lean Six Sigma methodologies were used to re-engineer the care that patients with diabetes receive. Key improvement initiatives focused on standardisation of accepted care practices through electronic templates, education and re-evaluation of patients to make 90-day, rapid cycle changes. Interventions were piloted in one primary care clinic then expanded to eight additional clinics. At the pilot site, the per cent of patients who completed the diabetic care bundle increased from 33% to 71% and the per cent of patients with diabetes with both A1c and blood pressure controlled increased from 31% to 43% (two-proportion test, p<0.01) postintervention. On rollout to eight additional clinics, the per cent of patients who completed the diabetic care bundle increased from 23% to 67% and the per cent of patients with diabetes with both their A1c and their blood pressure controlled increased from 22% to 41% (two-proportion test, p<0.01). After the interventions, nephropathy attention, A1c and blood pressure metrics exceeded HEDIS 75th percentile. Standardisation of accepted care practices for patients with diabetes improved compliance with diabetic care bundle completion and patient outcomes in the primary care setting.
Collapse
Affiliation(s)
- Tamar L Kutz
- Ambulatory Networks, Memorial Health System, Springfield, Illinois, USA
| | | | - Marshall Hale
- Memorial Physician Services, Memorial Health System, Springfield, Illinois, USA
| | - Virginia Dolan
- Memorial Physician Services, Memorial Health System, Springfield, Illinois, USA
| | - Gerald Suchomski
- Memorial Physician Services, Memorial Health System, Springfield, Illinois, USA
| | - Cassie Jaeger
- Department of Operations Improvement, Memorial Medical Center, Springfield, Illinois, USA
| |
Collapse
|
29
|
Pericleous M, Kelly C, Ala A, De Lusignan S. The role of the chronic care model in promoting the management of the patient with rare liver disease. Expert Rev Gastroenterol Hepatol 2018; 12:829-841. [PMID: 29976101 DOI: 10.1080/17474124.2018.1497483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The chronic care model (CCM) provides a holistic approach for managing chronic illnesses. Patients with rare liver diseases (RLD) have complex needs, impaired quality of life and often life-threatening complications. Most RLD meet the criteria for a long-term chronic condition and should be viewed through the prism of CCM. We aimed to ascertain whether the CCM has been considered for the frequently-encountered RLD. METHODS MEDLINE®/PubMed®/Cochrane/EMBASE were searched to identify publications relating to the use of the CCM for the management of six RLD. We identified 33 articles eligible for inclusion. RESULTS Six, eleven, one, thirteen, two and zero studies, discussed individual components of the CCM for autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), primary sclerosing cirrhosis (PSC), Wilsons disease (WD), alpha-1 antitrypsin deficiency (A1AD) and lysosomal acid lipase deficiency (LALd) respectively. We have not identified studies using the full CCM for any of the aforementioned RLD. DISCUSSION Unlike in common chronic conditions e.g. diabetes, there has been limited consideration of the use of CCM (or its components) for the management of RLD. This may reflect a reluctance of the clinical community to view these diseases as chronic or lack of healthcare policy investment in rare diseases in general.
Collapse
Affiliation(s)
- Marinos Pericleous
- a Department of Gastroenterology and Hepatology , Royal Surrey County Hospital NHS Foundation Trust , Guildford , UK.,b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
| | - Claire Kelly
- a Department of Gastroenterology and Hepatology , Royal Surrey County Hospital NHS Foundation Trust , Guildford , UK.,b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
| | - Aftab Ala
- a Department of Gastroenterology and Hepatology , Royal Surrey County Hospital NHS Foundation Trust , Guildford , UK.,b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
| | - Simon De Lusignan
- b Department of Clinical and experimental medicine , University of Surrey , Guildford , UK
| |
Collapse
|
30
|
Leung AK, Buckley K, Kurtz J. Sustainability of Clinical Benefits Gained During a Multidisciplinary Diabetes Shared Medical Appointment After Patients Return to Usual Care. Clin Diabetes 2018; 36:226-231. [PMID: 30078942 PMCID: PMC6053840 DOI: 10.2337/cd17-0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
IN BRIEF This study examined whether clinical benefits gained while participating in interdisciplinary diabetes shared medical appointments (SMAs) of finite duration (three to four monthly visits) are sustained after patients return to usual care. There are currently no publications confirming sustained clinical benefits beyond 9 months after SMA discharge without continued booster sessions to maintain benefits. At the end of the study, it was confirmed that both diabetes and cardiovascular benefits gained during multidisciplinary diabetes SMAs were sustained after patients were discharged to usual care without booster sessions for up to 3 years. The only exceptions were a statistically significant decrease in diastolic blood pressure at each yearly time point and a decrease in the percentage of patients meeting an A1C goal of <9% at year 2.
Collapse
Affiliation(s)
- Amy K. Leung
- Pharmacy Department, Phoenix Veterans Affairs Health Care System, Phoenix, AZ
| | - Kelsey Buckley
- Department of Pharmacy Practice, Mid-western University College of Pharmacy– Glendale, Glendale, AZ
| | - Julie Kurtz
- Nutrition Department, Phoenix Veterans Affairs Health Care System, Phoenix, AZ
| |
Collapse
|
31
|
Berkowitz SA, Eisenstat SA, Barnard LS, Wexler DJ. Multidisciplinary coordinated care for Type 2 diabetes: A qualitative analysis of patient perspectives. Prim Care Diabetes 2018; 12:218-223. [PMID: 29397351 PMCID: PMC6314296 DOI: 10.1016/j.pcd.2018.01.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/13/2017] [Accepted: 01/08/2018] [Indexed: 11/28/2022]
Abstract
AIMS To explore the patient perspective on coordinated multidisciplinary diabetes team care among a socioeconomically diverse group of adults with type 2 diabetes. METHODS Qualitative research design using 8 focus groups (n=53). We randomly sampled primary care patients with type 2 diabetes and conducted focus groups at their primary care clinic. Discussion prompts queried current perceptions of team care. Each focus group was audio recorded, transcribed verbatim, and independently coded by three reviewers. Coding used an iterative process. Thematic saturation was achieved. Data were analyzed using content analysis. RESULTS Most participants believed that coordinated multidisciplinary diabetes team care was a good approach, feeling that diabetes was too complicated for any one care team member to manage. Primary care physicians were seen as too busy to manage diabetes alone, and participants were content to be treated by other care team members, especially if there was a single point of contact and the care was coordinated. Participants suggested that an ideal multidisciplinary approach would additionally include support for exercise and managing socioeconomic challenges, components perceived to be missing from the existing approach to diabetes care. CONCLUSIONS Coordinated, multidisciplinary diabetes team care is understood by and acceptable to patients with type 2 diabetes.
Collapse
Affiliation(s)
- Seth A Berkowitz
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States; Diabetes Population Health Research Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Stephanie A Eisenstat
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Lily S Barnard
- University of California, San Francisco School of Medicine, San Francisco, CA, United States
| | - Deborah J Wexler
- Diabetes Population Health Research Unit, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| |
Collapse
|
32
|
Hartzler ML, Shenk M, Williams J, Schoen J, Dunn T, Anderson D. Impact of Collaborative Shared Medical Appointments on Diabetes Outcomes in a Family Medicine Clinic. DIABETES EDUCATOR 2018; 44:361-372. [DOI: 10.1177/0145721718776597] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose The purpose of this study is to evaluate the impact of a collaborative diabetes shared medical appointment on patient outcomes in an urban family medicine practice. Methods Fifty-nine patients were enrolled to participate in multiple shared medical appointments (SMAs) over 12 months. Baseline data included hemoglobin (A1C), lipids, systolic blood pressure (SBP), weight, adherence to American Diabetes Association (ADA) guidelines, and surveys, including the Problem Areas in Diabetes (PAID-2) scale and the Spoken Knowledge in Low Literacy in Diabetes Scale (SKILLD). A1C and SBP were evaluated at each visit. Lipid control was assessed at baseline and at 6 and 12 months. Adherence to ADA guidelines, SKILLD and PAID-2 survey scores, and number of antihyperglycemic and antihypertensive medications were also evaluated at 12 months. Results Thirty-eight patients completed the study. Compared with baseline, A1C and low-density lipoprotein cholesterol (LDL-C) levels decreased significantly over 12 months ( P < .001 and P = .004, respectively). More patients became compliant with the ADA guidelines throughout the course of the study. Specifically, more patients achieved the LDL-C goal of ≤100 mg/dL (2.59 mmol/L; P < .001), were prescribed appropriate antihypertensive medications ( P < .001) and aspirin ( P < .001), and received the pneumonia vaccine ( P < .001). PAID-2 and SKILLD survey scores also significantly improved over the course of the study ( P ≤ .001 and P = .003, respectively). Conclusion Short-term interdisciplinary SMAs decreased A1C and LDL-C, improved patient adherence to ADA guidelines, improved emotional distress related to diabetes, and increased knowledge of diabetes.
Collapse
Affiliation(s)
| | - McKenzie Shenk
- Cedarville University School of Pharmacy, Cedarville, Ohio
| | - Julie Williams
- Wright State University, School of Professional Psychology, Dayton, Ohio
| | - James Schoen
- Grandview Medical Center, Family Medicine, Dayton, Ohio
| | - Thomas Dunn
- Kettering Physicians Network, Family Medicine, Dayton, Ohio
| | | |
Collapse
|
33
|
Profili F, Bellini I, Zuppiroli A, Seghieri G, Barbone F, Francesconi P. Changes in diabetes care introduced by a Chronic Care Model-based programme in Tuscany: a 4-year cohort study. Eur J Public Health 2018; 27:14-19. [PMID: 28177441 DOI: 10.1093/eurpub/ckw181] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background In 2010, Tuscany (Italy) implemented a Chronic Care Model (CCM)-based programme for the management of chronic diseases. The study’s objective was to evaluate its impact on the care of patients with type 2 diabetes. Methods A population-based cohort study was performed on patients with diabetes, identified by an administrative data algorithm, exposed to a CCM-based programme versus patients not exposed (8486 patients in each group). The groups were matched using a propensity score approach and observed from 2011 to 2014. The outcomes measured were: mortality rate and hazard ratio (HR), hospitalisation incidence rate (IR) (all causes and diabetes-related diseases) and incidence rate ratio (IRR), and Guideline Composite Indicator (GCI) as proxy of adherence to guidelines (IR and IRR). Stratified Cox regression analysis and conditional fixed effect Poisson regression analyses were performed to compute HR and IRR. Results A significant improvement was observed for GCI (IRR 1.58; 95% CI 1.53–1.62) and for cardiovascular long-term complications (IRR 1.11; 95% CI 1.04–1.18). A protective effect was observed for neurological long-term complications (IRR 0.85; 95% CI 0.76–0.95), acute cardio-cerebrovascular long-term complications—stroke and ST segment elevation myocardial infarction—(IRR 0.81; 95% CI 0.71–0.92) and mortality (HR 0.88; 95% CI 0.81–0.96). Conclusion The implementation of a CCM-based programme was followed by better management and benefits for the health status of patients. The increase in hospitalisations for cardiovascular long-term complications could engender cost-efficacy issues, but a better integrated care (GPs and specialists) and a more appropriate specialist outpatient services organisation could avoid a part of these, while still maintaining the benefits seen.
Collapse
Affiliation(s)
| | - Irene Bellini
- Medical Specialisation School of Hygiene and Preventive Medicine, Florence, Italy
| | | | | | - Fabio Barbone
- Department of Medical Sciences, University of Trieste, Trieste, Italy.,Department of Medical and Biological Sciences, University of Udine, Udine, Italy
| | | |
Collapse
|
34
|
Lawrenson JG, Graham‐Rowe E, Lorencatto F, Burr J, Bunce C, Francis JJ, Aluko P, Rice S, Vale L, Peto T, Presseau J, Ivers N, Grimshaw JM. Interventions to increase attendance for diabetic retinopathy screening. Cochrane Database Syst Rev 2018; 1:CD012054. [PMID: 29333660 PMCID: PMC6491139 DOI: 10.1002/14651858.cd012054.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite evidence supporting the effectiveness of diabetic retinopathy screening (DRS) in reducing the risk of sight loss, attendance for screening is consistently below recommended levels. OBJECTIVES The primary objective of the review was to assess the effectiveness of quality improvement (QI) interventions that seek to increase attendance for DRS in people with type 1 and type 2 diabetes.Secondary objectives were:To use validated taxonomies of QI intervention strategies and behaviour change techniques (BCTs) to code the description of interventions in the included studies and determine whether interventions that include particular QI strategies or component BCTs are more effective in increasing screening attendance;To explore heterogeneity in effect size within and between studies to identify potential explanatory factors for variability in effect size;To explore differential effects in subgroups to provide information on how equity of screening attendance could be improved;To critically appraise and summarise current evidence on the resource use, costs and cost effectiveness. SEARCH METHODS We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, ProQuest Family Health, OpenGrey, the ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to identify randomised controlled trials (RCTs) that were designed to improve attendance for DRS or were evaluating general quality improvement (QI) strategies for diabetes care and reported the effect of the intervention on DRS attendance. We searched the resources on 13 February 2017. We did not use any date or language restrictions in the searches. SELECTION CRITERIA We included RCTs that compared any QI intervention to usual care or a more intensive (stepped) intervention versus a less intensive intervention. DATA COLLECTION AND ANALYSIS We coded the QI strategy using a modification of the taxonomy developed by Cochrane Effective Practice and Organisation of Care (EPOC) and BCTs using the BCT Taxonomy version 1 (BCTTv1). We used Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital (PROGRESS) elements to describe the characteristics of participants in the included studies that could have an impact on equity of access to health services.Two review authors independently extracted data. One review author entered the data into Review Manager 5 and a second review author checked them. Two review authors independently assessed risks of bias in the included studies and extracted data. We rated certainty of evidence using GRADE. MAIN RESULTS We included 66 RCTs conducted predominantly (62%) in the USA. Overall we judged the trials to be at low or unclear risk of bias. QI strategies were multifaceted and targeted patients, healthcare professionals or healthcare systems. Fifty-six studies (329,164 participants) compared intervention versus usual care (median duration of follow-up 12 months). Overall, DRS attendance increased by 12% (risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14; low-certainty evidence) compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted (RD 0.17, 95% CI 0.11 to 0.22) and general QI interventions (RD 0.12, 95% CI 0.09 to 0.15) were effective, particularly where baseline DRS attendance was low. All BCT combinations were associated with significant improvements, particularly in those with poor attendance. We found higher effect estimates in subgroup analyses for the BCTs 'goal setting (outcome)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients, and 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting healthcare professionals.Ten studies (23,715 participants) compared a more intensive (stepped) intervention versus a less intensive intervention. In these studies DRS attendance increased by 5% (RD 0.05, 95% CI 0.02 to 0.09; moderate-certainty evidence).Fourteen studies reporting any QI intervention compared to usual care included economic outcomes. However, only five of these were full economic evaluations. Overall, we found that there is insufficient evidence to draw robust conclusions about the relative cost effectiveness of the interventions compared to each other or against usual care.With the exception of gender and ethnicity, the characteristics of participants were poorly described in terms of PROGRESS elements. Seventeen studies (25.8%) were conducted in disadvantaged populations. No studies were carried out in low- or middle-income countries. AUTHORS' CONCLUSIONS The results of this review provide evidence that QI interventions targeting patients, healthcare professionals or the healthcare system are associated with meaningful improvements in DRS attendance compared to usual care. There was no statistically significant difference between interventions specifically aimed at DRS and those which were part of a general QI strategy for improving diabetes care. This is a significant finding, due to the additional benefits of general QI interventions in terms of improving glycaemic control, vascular risk management and screening for other microvascular complications. It is likely that further (but smaller) improvements in DRS attendance can also be achieved by increasing the intensity of a particular QI component or adding further components.
Collapse
Affiliation(s)
- John G Lawrenson
- City University of LondonCentre for Applied Vision Research, School of Health SciencesNorthampton SquareLondonUKEC1V 0HB
| | - Ella Graham‐Rowe
- City University LondonSchool of Health Sciences, Centre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Fabiana Lorencatto
- City University LondonSchool of Health Sciences, Centre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Jennifer Burr
- University of St AndrewsSchool of Medicine, Medical and Biological Sciences BuildingFifeUKKY16 9TF
| | - Catey Bunce
- Kings College LondonDepartment of Primary Care & Public Health Sciences4th Floor, Addison HouseGuy's CampusLondonUKSE1 1UL
| | - Jillian J Francis
- City University LondonSchool of Health Sciences, Centre for Health Services ResearchNorthampton SquareLondonUKEC1V 0HB
| | - Patricia Aluko
- Newcastle UniversityNational Institute for Health Research (NIHR) Innovation ObservatoryTimes Central offices, 4th Floor, GallowgateNewcastle upon TyneUKNE1 4BF
| | - Stephen Rice
- Newcastle UniversityInstitute of Health & SocietyNewcastle upon TyneUKNE2 4AX
| | - Luke Vale
- Newcastle UniversityInstitute of Health & SocietyNewcastle upon TyneUKNE2 4AX
| | - Tunde Peto
- Queen's University BelfastCentre for Public HealthBelfastUKBT12 6BA
| | - Justin Presseau
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaOntarioCanadaK1H 8L6
| | - Noah Ivers
- Women's College HospitalDepartment of Family and Community Medicine76 Grenville StreetTorontoONCanadaM5S 1B2
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology Program501 Smyth RoadOttawaOntarioCanadaK1H 8L6
- University of OttawaDepartment of MedicineOttawaONCanada
| | | |
Collapse
|
35
|
McManus MC, Cramer RJ, Boshier M, Akpinar-Elci M, Van Lunen B. Mental Health and Drivers of Need in Emergent and Non-Emergent Emergency Department (ED) Use: Do Living Location and Non-Emergent Care Sources Matter? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E129. [PMID: 29342846 PMCID: PMC5800228 DOI: 10.3390/ijerph15010129] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 11/16/2022]
Abstract
Emergency department (ED) utilization has increased due to factors such as admissions for mental health conditions, including suicide and self-harm. We investigate direct and moderating influences on non-emergent ED utilization through the Behavioral Model of Health Services Use. Through logistic regression, we examined correlates of ED use via 2014 New York State Department of Health Statewide Planning and Research Cooperative System outpatient data. Consistent with the primary hypothesis, mental health admissions were associated with emergent use across models, with only a slight decrease in effect size in rural living locations. Concerning moderating effects, Spanish/Hispanic origin was associated with increased likelihood for emergent ED use in the rural living location model, and non-emergent ED use for the no non-emergent source model. 'Other' ethnic origin increased the likelihood of emergent ED use for rural living location and no non-emergent source models. The findings reveal 'need', including mental health admissions, as the largest driver for ED use. This may be due to mental healthcare access, or patients with mental health emergencies being transported via first responders to the ED, as in the case of suicide, self-harm, manic episodes or psychotic episodes. Further educating ED staff on this patient population through gatekeeper training may ensure patients receive the best treatment and aid in driving access to mental healthcare delivery changes.
Collapse
Affiliation(s)
- Moira C McManus
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Robert J Cramer
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Maureen Boshier
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Muge Akpinar-Elci
- Community and Environmental Health, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4259, USA.
| | - Bonnie Van Lunen
- Physical Therapy and Athletic Training, College of Health Sciences, Old Dominion University; Norfolk, VA 757-683-4519, USA.
| |
Collapse
|
36
|
Wan EYF, Fung CSC, Jiao FF, Yu EYT, Chin WY, Fong DYT, Wong CKH, Chan AKC, Chan KHY, Kwok RLP, Lam CLK. Five-Year Effectiveness of the Multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) on Diabetes-Related Complications and Health Service Uses-A Population-Based and Propensity-Matched Cohort Study. Diabetes Care 2018; 41:49-59. [PMID: 29138274 DOI: 10.2337/dc17-0426] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 09/23/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the 5-year effectiveness of a multidisciplinary Risk Assessment and Management Programme-Diabetes Mellitus (RAMP-DM) in primary care patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A 5-year prospective cohort study was conducted with 121,584 Chinese primary care patients with type 2 DM who were recruited between August 2009 and June 2011. Missing data were dealt with multiple imputations. After excluding patients with prior diabetes mellitus (DM)-related complications and one-to-one propensity score matching on all patient characteristics, 26,718 RAMP-DM participants and 26,718 matched usual care patients were followed up for a median time of 4.5 years. The effect of RAMP-DM on nine DM-related complications and all-cause mortality were evaluated using Cox regressions. The first incidence for each event was used for all models. Health service use was analyzed using negative binomial regressions. Subgroup analyses on different patient characteristics were performed. RESULTS The cumulative incidence of all events (DM-related complications and all-cause mortality) was 23.2% in the RAMP-DM group and 43.6% in the usual care group. RAMP-DM led to significantly greater reductions in cardiovascular disease (CVD) risk by 56.6% (95% CI 54.5, 58.6), microvascular complications by 11.9% (95% CI 7.0, 16.6), mortality by 66.1% (95% CI 64.3, 67.9), specialist attendance by 35.0% (95% CI 33.6, 36.4), emergency attendance by 41.2% (95% CI 39.8, 42.5), and hospitalizations by 58.5% (95% CI 57.2, 59.7). Patients with low baseline CVD risks benefitted the most from RAMP-DM, which decreased CVD and mortality risk by 60.4% (95% CI 51.8, 67.5) and 83.6% (95% CI 79.3, 87.0), respectively. CONCLUSIONS This naturalistic study highlighted the importance of early optimal DM control and risk factor management by risk stratification and multidisciplinary, protocol-driven, chronic disease model care to delay disease progression and prevent complications.
Collapse
Affiliation(s)
- Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Colman Siu Cheung Fung
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Fang Fang Jiao
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Esther Yee Tak Yu
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Weng Yee Chin
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Daniel Yee Tak Fong
- School of Nursing, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Carlos King Ho Wong
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Anca Ka Chun Chan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Karina Hiu Yen Chan
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Ruby Lai Ping Kwok
- Primary and Community Services Department, Hospital Authority Head Office, Hong Kong Hospital Authority, Hong Kong, People's Republic of China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, Ap Lei Chau Clinic, Ap Lei Chau, The University of Hong Kong, Hong Kong, People's Republic of China
| |
Collapse
|
37
|
Affiliation(s)
- Valerie S. Ganetsky
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA
| | | | - Steven T. Kaufman
- Cooper University Hospital Urban Health Institute, Camden, NJ
- Cooper Medical School of Rowan University, Camden, NJ
| |
Collapse
|
38
|
Lestoquoy AS, Laird LD, Mitchell S, Gergen-Barnett K, Negash NL, McCue K, Enad R, Gardiner P. Living with chronic pain: Evaluating patient experiences with a medical group visit focused on mindfulness and non-pharmacological strategies. Complement Ther Med 2017; 35:33-38. [PMID: 29154064 DOI: 10.1016/j.ctim.2017.09.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/01/2017] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Little is known about the acceptance of non-pharmacological group strategies delivered to low income racially diverse patients with chronic pain and depression. This paper examines how the Integrative Medical Group Visit (IMGV) addresses many of the deficits identified with usual care. DESIGN AND SETTING Six IMGVs cohorts were held at a safety net hospital and two federally funded community health centres. Data was gathered through focus groups. Transcripts were analysed using both a priori codes and inductive coding. INTERVENTION The intervention included ten sessions of Integrative Medical Group Visits with a primary care provider and a meditation instructor. The curriculum uses principles of Mindfulness Based Stress Reduction and evidence based integrative medicine. The visit is structured similarly to other group medical visits. MAIN OUTCOME MEASURES Data was gathered through four focus groups held after the cohorts were completed. RESULTS Participants (N=20) were largely low income minority adults with chronic pain and comorbid depression. Six themes emerged from the coding including: chronic pain is isolating; group treatment contributes to better coping with pain; loss of control and autonomy because of the unpredictability of pain as well as dependence on medication and frequent medical appointments; groups improve agency and control over one's health condition; navigating the healthcare system and unsatisfactory treatment options; and changes after the IMGV due to non-pharmacological health management. CONCLUSIONS The IMGV is a promising format of delivering integrative care for chronic pain and depression which addresses many of the problems identified by patients in usual care.
Collapse
Affiliation(s)
- Anna Sophia Lestoquoy
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Lance D Laird
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Suzanne Mitchell
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA
| | - Katherine Gergen-Barnett
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - N Lily Negash
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Kelly McCue
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Racquel Enad
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA
| | - Paula Gardiner
- Department of Family Medicine, Boston Medical Center, Dowling 5 South, 1 Boston Medical Center Place, Boston, MA 02118, USA; Boston University School of Medicine, 72 E Concord St, Boston, MA 02118, USA.
| |
Collapse
|
39
|
Siebenhofer A, Paulitsch MA, Pregartner G, Berghold A, Jeitler K, Muth C, Engler J. Cluster-randomized controlled trials evaluating complex interventions in general practices are mostly ineffective: a systematic review. J Clin Epidemiol 2017; 94:85-96. [PMID: 29111470 DOI: 10.1016/j.jclinepi.2017.10.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 09/14/2017] [Accepted: 10/17/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate how frequently complex interventions are shown to be superior to routine care in general practice-based cluster-randomized controlled studies (c-RCTs) and to explore whether potential differences explain results that come out in favor of a complex intervention. STUDY DESIGN AND SETTING We performed an unrestricted search in the Central Register of Controlled Trials, MEDLINE, and EMBASE. Included were all c-RCTs that included a patient-relevant primary outcome in a general practice setting with at least 1-year follow-up. We extracted effect sizes, P-values, intracluster correlation coefficients (ICCs), and 22 quality aspects. RESULTS We identified 29 trials with 99 patient-relevant primary outcomes. After adjustment for multiple testing on a trial level, four outcomes (4%) in four studies (14%) remained statistically significant. Of the 11 studies that reported ICCs, in 8, the ICC was equal to or smaller than the assumed ICC. In 16 of the 17 studies with available sample size calculation, effect sizes were smaller than anticipated. CONCLUSION More than 85% of the c-RCTs failed to demonstrate a beneficial effect on a predefined primary endpoint. All but one study were overly optimistic with regard to the expected treatment effect. This highlights the importance of weighing up the potential merit of new treatments and planning prospectively, when designing clinical studies in a general practice setting.
Collapse
Affiliation(s)
- Andrea Siebenhofer
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany; Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Auenbruggerplatz 2/9/IV, Graz 8036, Austria.
| | - Michael A Paulitsch
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Gudrun Pregartner
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2, Graz 8036, Austria
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2, Graz 8036, Austria
| | - Klaus Jeitler
- Institute of General Practice and Evidence-based Health Services Research, Medical University of Graz, Auenbruggerplatz 2/9/IV, Graz 8036, Austria; Institute for Medical Informatics, Statistics and Documentation, Medical University Graz, Auenbruggerplatz 2, Graz 8036, Austria
| | - Christiane Muth
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| | - Jennifer Engler
- Institute of General Practice, Goethe University Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt am Main 60590, Germany
| |
Collapse
|
40
|
Golden SH, Maruthur N, Mathioudakis N, Spanakis E, Rubin D, Zilbermint M, Hill-Briggs F. The Case for Diabetes Population Health Improvement: Evidence-Based Programming for Population Outcomes in Diabetes. Curr Diab Rep 2017; 17:51. [PMID: 28567711 PMCID: PMC5553206 DOI: 10.1007/s11892-017-0875-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW The goal of this review is to describe diabetes within a population health improvement framework and to review the evidence for a diabetes population health continuum of intervention approaches, including diabetes prevention and chronic and acute diabetes management, to improve clinical and economic outcomes. RECENT FINDINGS Recent studies have shown that compared to usual care, lifestyle interventions in prediabetes lower diabetes risk at the population-level and that group-based programs have low incremental medial cost effectiveness ratio for health systems. Effective outpatient interventions that improve diabetes control and process outcomes are multi-level, targeting the patient, provider, and healthcare system simultaneously and integrate community health workers as a liaison between the patient and community-based healthcare resources. A multi-faceted approach to diabetes management is also effective in the inpatient setting. Interventions shown to promote safe and effective glycemic control and use of evidence-based glucose management practices include provider reminder and clinical decision support systems, automated computer order entry, provider education, and organizational change. Future studies should examine the cost-effectiveness of multi-faceted outpatient and inpatient diabetes management programs to determine the best financial models for incorporating them into diabetes population health strategies.
Collapse
Affiliation(s)
- Sherita Hill Golden
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA.
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Nisa Maruthur
- Departments of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
| | - Elias Spanakis
- Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland Medical System, Baltimore, MD, USA
| | - Daniel Rubin
- Division of Endocrinology and Metabolism, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | - Felicia Hill-Briggs
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite no. 333, Baltimore, MD, 21287, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
41
|
Wolters RJ, Braspenning JCC, Wensing M. Impact of primary care on hospital admission rates for diabetes patients: A systematic review. Diabetes Res Clin Pract 2017; 129:182-196. [PMID: 28544924 DOI: 10.1016/j.diabres.2017.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/02/2017] [Indexed: 11/17/2022]
Abstract
High-quality primary care for diabetes patients may be related to lowered hospital admissions. A systematic search was performed to assess the impact of structure, process, and outcome of primary diabetes care on hospital admission rates, considering patient characteristics. Studies on diabetes patients in primary care with hospitalisation rates as outcomes published between January 1996 and December 2015 were included. Indicators of quality of care (access, continuity and structure of care, process, and outcome indicators) and patient characteristics (age, gender, ethnicity, insurance, socio-economic status, diabetes characteristics, co-morbidity, and health-related lifestyle) were extracted. After assessment of the strength of evidence, characteristics of care and diabetes patients were presented in relation to the likelihood of hospitalisation. Thirty-one studies were identified. A regular source of primary care and a well-controlled HbA1c level decreased the likelihood of hospitalisation. Other aspects of care were less consistent. Patients' age, co-morbidity, and socio-economic status were related to higher hospitalisation. Gender and health-related lifestyle showed no relationship. Studies were heterogeneous in design, sample, and healthcare system. Different definitions of diabetes and unscheduled admissions limited comparisons. In healthcare systems where diabetes patients have a regular source of primary care, hospital admission rates cannot be meaningfully related to primary care characteristics.
Collapse
Affiliation(s)
- R J Wolters
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein 21, 114 IQ Healthcare, 6525 EZ Nijmegen, The Netherlands.
| | - J C C Braspenning
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein 21, 114 IQ Healthcare, 6525 EZ Nijmegen, The Netherlands.
| | - M Wensing
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein 21, 114 IQ Healthcare, 6525 EZ Nijmegen, The Netherlands; Department of General Practice and Health Services Research Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany.
| |
Collapse
|
42
|
Jackson BM, Gutierrez ML, Relyea GE, Carlton EL, Ahn S, Binkley BL, Bailey JE. Unmet Primary Care Needs in Diabetic Patients with Multimorbidity in a Medically Underserved Area. Health Serv Res Manag Epidemiol 2017; 4:2333392817702760. [PMID: 28540336 PMCID: PMC5431606 DOI: 10.1177/2333392817702760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/21/2017] [Indexed: 12/05/2022] Open
Abstract
Background: Diabetic patients with multimorbidity in medically underserved minority communities are less engaged in primary care and experience high emergency department (ED) utilization. This study assesses unmet primary care needs among diabetic patients in a medically underserved area (MUA). Community Context: A suburb of Memphis—Whitehaven, Tennessee (Shelby County, ZIP codes 38109 and 38116)—majority African American (96.6%) with 30.5% below the poverty level. Methods: Community case study using multiple data sources including diabetes registry, individual interviews, focus groups, and a survey of 30 ED patients with diabetes and multimorbidity. Results: Diabetes registry data indicated that 95.5% of 5723 diabetic patients had multimorbidity. Over 91.5% were uncontrolled at some point in 2014 to 2015. Only 83% of patients with diabetes and multimorbidity reported having a primary care provider (PCP) and those without a PCP were more likely to report delays in needed care. Patients expressed strong interest in health coaching (88%) and receiving text messages from the doctor’s office (73%). Individual patient interviews (n = 9) and focus groups (n = 11) revealed common primary care and self-care experiences and needs including diabetes education, improved patient–provider communication, health-care access and coverage, and strengthened primary care and community. Conclusion: This study demonstrates that almost 1 in 5 ED complex diabetic patients in an MUA do not have a PCP, and that difficulty accessing primary care often results in patients forgoing needed care. Qualitative findings support these conclusions. These results suggest that primary care capacity and infrastructure to support diabetes self-care need strengthening in MUAs.
Collapse
Affiliation(s)
- Bianca M Jackson
- Division of Health Systems Management and Policy, School of Public Health, University of Memphis, Memphis, TN, USA.,Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Mary Lou Gutierrez
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA
| | - George E Relyea
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, TN, USA
| | - Erik L Carlton
- Division of Health Systems Management and Policy, School of Public Health, University of Memphis, Memphis, TN, USA
| | - SangNam Ahn
- Division of Health Systems Management and Policy, School of Public Health, University of Memphis, Memphis, TN, USA
| | - Bonnie L Binkley
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA
| | - James E Bailey
- Center for Health System Improvement, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
43
|
Sadikot SM, Das AK, Wilding J, Siyan A, Zargar AH, Saboo B, Aravind SR, Sosale B, Kalra S, Vijayakumar G, Manojan KK, Maheshwari A, Panda JK, Banerjee S, Chawla R, Vasudevan SP, Sundar OSS, Kesavadev J. Consensus recommendations on exploring effective solutions for the rising cost of diabetes. Diabetes Metab Syndr 2017; 11:141-147. [PMID: 28325543 DOI: 10.1016/j.dsx.2017.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 03/03/2017] [Indexed: 12/16/2022]
Abstract
Diabetes remains asymptomatic for a long period of time and its real burden gets noticed only once the complications set in. The number of individuals affected with the disease is also on the rise and more so in the low income countries. This scenario calls for urgent precautionary measures that need to be undertaken to equip ourselves to fight against this chronic disease. Individuals with financial constraints cannot afford to access even the basic treatment facilities and thus stands the most burdened. The International Diabetes Federation calls for 'Eyes on Diabetes' for the society to focus on early screening and early intervention. The rising cost of diabetes results from delayed and denied treatment. The panel discussion organized as a part of 4th Annual global diabetes convention of Jothydev's Professional Education Forum (JPEF, 2016) facilitated a platform to address diabetes as a serious health concern that needs to be given immediate priority by the policymakers as well as public and also to discuss about the feasible measures that will help achieve cost effective and affordable diabetes treatment. This was followed by in-depth literature search and finally a set of recommendations have been arrived at by the key opinion leaders to realize the dream of affordable diabetes care to all deserving individuals.
Collapse
Affiliation(s)
- Shaukat M Sadikot
- Department of Endocrinology/Diabetology, Jaslok Hospital & Research Centre, Mumbai, India
| | - Ashok Kumar Das
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
| | - John Wilding
- Institute of Ageing and Chronic Disease, University of Liverpool, United Kingdom
| | | | | | - Banshi Saboo
- Dia Care & Hormone Clinic, Ahmedabad, Gujarat, India
| | | | | | - Sanjay Kalra
- Department of Endocrinology, Bharati Hospital, Karnal, Haryana, India
| | - G Vijayakumar
- Medical Trust Hospital, Kulanada, Pathanamthitta, Kerala, India
| | - K K Manojan
- Sree Gokulam Medical College, Trivandrum, Kerala, India
| | - Anuj Maheshwari
- Department of Internal Medicine, Babu Banarsi Das University, Lucknow, India
| | - Jayant K Panda
- Department of Medicine, SCB Medical College, Cuttack, India
| | - Samar Banerjee
- Department of Medicine, Vivekananda Institute of Medical Sciences, Kolkata, India
| | | | | | - O S Syam Sundar
- Department of Medicine, Government General Hospital, Trivandrum, India
| | | |
Collapse
|
44
|
Mogre V, Abanga ZO, Tzelepis F, Johnson NA, Paul C. Adherence to and factors associated with self-care behaviours in type 2 diabetes patients in Ghana. BMC Endocr Disord 2017; 17:20. [PMID: 28340613 PMCID: PMC5366118 DOI: 10.1186/s12902-017-0169-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 03/18/2017] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Previous research has failed to examine more than one self-care behaviour in type 2 diabetes patients in Ghana. The purpose of this study is to investigate adult Ghanaian type 2 diabetes patients' adherence to four self-care activities: diet (general and specific), exercise, self-monitoring of blood glucose (SMBG) and foot care. METHODS Consenting type 2 diabetes patients attending diabetes outpatient clinic appointments at three hospitals in the Tamale Metropolis of Ghana completed a cross-sectional survey comprising the Summary of Diabetes Self-Care Activities Measure, and questions about demographic characteristics and diabetes history. Height and weight were also measured. Multiple linear regression analyses were conducted to identify the factors associated with adherence to each of the four self-care behaviours. RESULTS In the last 7 days, participants exercised for a mean (SD) of 4.78 (2.09) days and followed diet, foot care and SMBG for a mean (SD) of 4.40 (1.52), 2.86 (2.16) and 2.15 (0.65) days, respectively. More education was associated with a higher frequency of reported participation in exercise (r = 0.168, p = 0.022), following a healthy diet (r = 0.223, p = 0.002) and foot care (r = 0.153, p = 0.037) in the last 7 days. Males reported performing SMBG (r = 0.198, p = 0.007) more frequently than their female counterparts. CONCLUSION Adherence to diet, SMBG and checking of feet were relatively low. People with low education and women may need additional support to improve adherence to self-care behaviours in this type 2 diabetes population.
Collapse
Affiliation(s)
- Victor Mogre
- Department of Health Professions Education, School of Medicine and Health Sciences, University for Development Studies, P. O. Box TL 1883, Tamale, Ghana.
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
| | - Zakaria Osman Abanga
- Department of Community Nutrition, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Flora Tzelepis
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, Locked bag 1000, New Lambton, NSW, 2305, Australia
- Hunter New England Population Health, Hunter New England Local Health District, Locked Mail Bag 10, Wallsend, NSW, 2287, Australia
| | - Natalie A Johnson
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Christine Paul
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, Locked bag 1000, New Lambton, NSW, 2305, Australia
| |
Collapse
|
45
|
Kirsh SR, Aron DC, Johnson KD, Santurri LE, Stevenson LD, Jones KR, Jagosh J. A realist review of shared medical appointments: How, for whom, and under what circumstances do they work? BMC Health Serv Res 2017; 17:113. [PMID: 28160771 PMCID: PMC5291948 DOI: 10.1186/s12913-017-2064-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 01/31/2017] [Indexed: 12/22/2022] Open
Abstract
Background Shared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances. Methods Realist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations). Results Nine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one’s ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others’ illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients’ needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust. Conclusions Nine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.
Collapse
Affiliation(s)
- Susan R Kirsh
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - David C Aron
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA. .,School of Medicine, Case Western Reserve University, Cleveland, OH, USA. .,Weatherhead School of Management, Case Western Reserve University, Cleveland, OH, USA.
| | - Kimberly D Johnson
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,College of Nursing, University of Cincinnati, Cincinnati, OH, USA
| | - Laura E Santurri
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA.,School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | | | - Katherine R Jones
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Justin Jagosh
- Centre for the Advancement of Realist Evaluation and Synthesis, University of Liverpool, Liverpool, UK
| |
Collapse
|
46
|
Martin OJ, Wu WC, Taveira TH, Eaton CB, Sharma SC. Multidisciplinary Group Behavioral and Pharmacologic Intervention for Cardiac Risk Reduction in Diabetes. DIABETES EDUCATOR 2017; 33:118-27. [PMID: 17272798 DOI: 10.1177/0145721706297456] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of a multidisciplinary team providing both education and medication management in a group setting for cardiac risk reduction in patients with diabetes mellitus. METHODS The electronic medical records of patients with diabetes who participated in group behavioral and pharmacologic interventions for cardiac risk reduction during May to October 2002 at the Providence VA Medical Center were reviewed. Forty-one veterans with diabetes mellitus attended the weekly sessions of a diabetes education and intervention program directed by pharmacists for 1 month. Two groups of 15 to 20 patients received four 1.5-hour diabetes self-management education classes provided by a multidisciplinary team consisting of a pharmacist (leader), nurse educator, dietician, physical therapist, and social worker and four 1-hour group medication adjustment sessions provided by the pharmacist. Pharmacists followed medication adjustment algorithms for blood pressure, diabetes, and cholesterol management previously developed in collaboration with physician specialists in the field. Baseline and 3-month after-intervention data were collected for glycosylated hemoglobin A1C (A1C), systolic and diastolic blood pressure (SBP and DBP, respectively), low-density lipoprotein cholesterol, and body mass index. RESULTS Thirty-six patients attended 4 sessions, and 5 patients attended 3 sessions. All parameters improved after the intervention, with significant reductions in A1C (-1.5% +/- 1.0%) and DBP (-5 mm Hg). Reductions were further accentuated when baseline values were abnormal, with significant improvement in A1C (-2.0% +/- 0.5%), SBP (-14 +/- 3 mm Hg), and DBP (-13 +/- 3 mm Hg). CONCLUSIONS Short-term multidisciplinary group behavioral and pharmacologic intervention programs may be effective in improving cardiac risk factors in patients with diabetes.
Collapse
Affiliation(s)
- Oanh J Martin
- Pharmacy Service, Veterans Affairs Medical Center, and the Department of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences, Providence VA Medical Center, Providence, Rhode Island (Dr Martin)
| | - Wen-Chih Wu
- Medical Service, Veterans Affairs Medical Center, Providence VA Medical Center, and Brown Medical School, Brown University, Providence, Rhode Island (Dr Wu, Dr Sharma)
| | - Tracey H Taveira
- Pharmacy Service, Veterans Affairs Medical Center, and the Department of Pharmacy Practice, University of Rhode Island, College of Pharmacy (Dr Taveira)
| | - Charles B Eaton
- The Center for Primary Care and Prevention, Memorial Hospital of Rhode Island, Pawtucket, Rhode Island, and the Department of Family Medicine, Brown Medical School, Brown University, Providence, Rhode Island (Dr Eaton)
| | - Satish C Sharma
- Medical Service, Veterans Affairs Medical Center, Providence VA Medical Center, and Brown Medical School, Brown University, Providence, Rhode Island (Dr Wu, Dr Sharma)
| |
Collapse
|
47
|
Wingate L, Graffy J, Holman D, Simmons D. Can peer support be cost saving? An economic evaluation of RAPSID: a randomized controlled trial of peer support in diabetes compared to usual care alone in East of England communities. BMJ Open Diabetes Res Care 2017; 5:e000328. [PMID: 29225890 PMCID: PMC5706488 DOI: 10.1136/bmjdrc-2016-000328] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 06/22/2017] [Accepted: 07/11/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Diabetes peer support, where one person with diabetes helps others, may improve diabetes management. The objective of this study was to perform a cost analysis of peer support strategies used in RAndomized controlled trial of Peer Support in type 2 Diabetes. METHODS We performed a 2×2 factorial randomized cluster controlled trial in England. People with type 2 diabetes were invited to participate as either 'peer' or 'peer support facilitator' (PSF) through postal invitation predominantly from general practice. Clusters, based on local communities, were each randomly assigned to one arm of group, 1:1, both group and 1:1 or control interventions. The intervention was delivered over 8-12 months by trained PSFs, supported by monthly meetings with a diabetes nurse. Out-of-pocket expenses/service utilization were self-reported at baseline, midpoint and on trial completion. Intervention costs were collated. Non-hospital costs used National Health Service (NHS) reference costs. Hospital payments were obtained from one local commissioning group and mean payments calculated. The analysis employed a societal perspective. Costs were evaluated at the conclusion of the trial. RESULTS Participants (n=1299) were recruited across 130 clusters. The four arms were well balanced and matched (60% male, mean diabetes duration 9.5 years, mean glycated haemoglobin (HbA1c) 7.4+/-1.3%, 17% insulin treated). Implementation costs at 2013 rates were £13.84/participant/annum, participant out-of-pocket expenses for any intervention were £11.41/participant/annum and the NHS-incurred costs were reduced by £138.38/participant/annum. Savings for the 1:1, group and any intervention were £233.65, £90.52 and £113.13/participant/annum, respectively. CONCLUSIONS We conclude that both 1:1 and group diabetes peer support over 8-12 months are cost saving in this setting, although much of the benefit is largely derived by differences in self-reported healthcare utilization. Long-term benefits should be investigated. TRIAL REGISTRATION NUMBER ISRCTN66963621.
Collapse
Affiliation(s)
- La’Marcus Wingate
- Department of Clinical and Administrative Pharmacy, Howard University, Washington DC, Washington, USA
| | - Jonathan Graffy
- Department of Public Health and Primary Care, Primary Care Unit, University of Cambridge, Cambridge, UK
| | - Daniel Holman
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - David Simmons
- MacArthur Clinical School, Western Sydney University, Campbelltown, Australia
- Wolfson Diabetes and Endocrinology Clinic, Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
48
|
Gardiner P, Lestoquoy AS, Gergen-Barnett K, Penti B, White LF, Saper R, Fredman L, Stillman S, Lily Negash N, Adelstein P, Brackup I, Farrell-Riley C, Kabbara K, Laird L, Mitchell S, Bickmore T, Shamekhi A, Liebschutz JM. Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression. Contemp Clin Trials 2016; 54:25-35. [PMID: 27979754 DOI: 10.1016/j.cct.2016.12.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 12/07/2016] [Accepted: 12/10/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Given the public health crisis of opioid overprescribing for pain, there is a need for evidence-based non pharmacological treatment options that effectively reduce pain and depression. We aim to examine the effectiveness of the Integrative Medical Group Visits (IMGV) model in reducing chronic pain and depressive symptoms, as well as increasing pain self-management. METHODS This paper details the study design and implementation of an ongoing randomized controlled trial of the IMGV model as compared to primary care visits. The research aims to determine if the IMGV model is effective in achieving: a) a reduction in self-reported pain and depressive symptoms and 2) an improvement in the self-management of pain, through increasing pain self-efficacy and reducing use of self-reported pain medication. We intend to recruit 154 participants to be randomized in our intervention, the IMGV model (n=77) and to usual care (n=77). CONCLUSIONS Usual care of chronic pain through pharmacological treatment has mixed evidence of efficacy and may not improve quality of life or functional status. We aim to conduct a randomized controlled trial to evaluate the effectiveness of the IMGV model as compared to usual care in reducing self-reported pain and depressive symptoms as well as increasing pain management skills.
Collapse
Affiliation(s)
- Paula Gardiner
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States.
| | - Anna Sophia Lestoquoy
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Katherine Gergen-Barnett
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Brian Penti
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Laura F White
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, United States
| | - Robert Saper
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Lisa Fredman
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Sarah Stillman
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - N Lily Negash
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | | | - Ivy Brackup
- DotHouse Health Center, Dorchester, MA, United States
| | | | - Karim Kabbara
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Lance Laird
- Division of Graduate Medical Sciences, Boston University School of Medicine, Boston, MA, United States
| | - Suzanne Mitchell
- Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, United States
| | - Timothy Bickmore
- College of Computer & Information Science, Northeastern University, Boston, MA, United States
| | - Ameneh Shamekhi
- College of Computer & Information Science, Northeastern University, Boston, MA, United States
| | - Jane M Liebschutz
- Clinical Addictions Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine and Public Health, Boston, MA, United States
| |
Collapse
|
49
|
Ziemer DC, Miller CD, Rhee MK, Doyle JP, Watkins C, Cook CB, Gallina DL, El-Kebbi IM, Barnes CS, Dunbar VG, Branch WT, Phillips LS. Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting. DIABETES EDUCATOR 2016; 31:564-71. [PMID: 16100332 DOI: 10.1177/0145721705279050] [Citation(s) in RCA: 165] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose The purpose of this study was to determine whether “clinical inertia”—inadequate intensification of therapy by the provider—could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. Methods In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). Conclusions Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.
Collapse
Affiliation(s)
- David C Ziemer
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Christopher D Miller
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Mary K Rhee
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Joyce P Doyle
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Clyde Watkins
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Curtiss B Cook
- The Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia, and Mayo Clinic, Scottsdale, Arizona (Dr Cook)
| | - Daniel L Gallina
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Imad M El-Kebbi
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Catherine S Barnes
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Virginia G Dunbar
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - William T Branch
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| | - Lawrence S Phillips
- Divisions of Endocrinology and Metabolism and General Medicine, Department of Medicine, Emory University School of Medicine, Grady Health Systems, Atlanta, Georgia
| |
Collapse
|
50
|
Martinez NC, Tripp-Reimer T. Diabetes Nurse Educators' Prioritized Elder Foot Care Behaviors. DIABETES EDUCATOR 2016; 31:858-68. [PMID: 16288093 DOI: 10.1177/0145721705282252] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this study was to identify diabetes nurse educators' perceptions of the most important foot care behaviors for elderly people to enact in daily care. Methods A structured, open-ended questionnaire was mailed to a regionally stratified random sample of 90 diabetes nurse educators. Subjects were asked to identify and rank order 8 foot care behaviors perceived important for elderly people with diabetes to enact daily. Data were transcribed and coded into categories and domains using descriptive content analysis. Results Forty-seven diabetes nurse educators responded with a total of 346 foot care behaviors perceived important for elders. Twenty-one major foot care behavior content categories were grouped into 4 domains of descending importance: foot/nail care, footwear/shoes, general health, and foot emergencies. Conclusions Diabetes nurse educators generated a range of baseline data for developing a reliable, valid, and patient foot care knowledge outcome measure to support national diabetes patient education and self-management program guidelines.
Collapse
|