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1.  Who is targeted for lifestyle advice? A cross-sectional survey in two general practices. 
BACKGROUND: Recent health promotion guidelines reimbursed primary health care teams for targeting lifestyle advice to patients at risk of cardiovascular disease. However, it is unclear whether primary health care teams do target advice, who is targeted, and whether the advice is acted upon. AIM: To assess which factors predict the targeting and recall of lifestyle advice. METHOD: A total of 370 patients with, and 192 without, a computer record of risk factors for cardiovascular disease (hypertension, diabetes, ischaemic heart disease/myocardial infarction/angina, a body mass index > or = 30) from two contrasting Wessex practices were sent a postal questionnaire about medical conditions, recall of lifestyle advice, current lifestyle, and their perceptions about the health of their lifestyle. RESULTS: Seventy-seven per cent of patients responded. There was good agreement between listed risk factors and patients reporting a risk factor (kappa = 0.60), which was similar for both sexes and better in older age groups. Recall of lifestyle advice was not significantly affected by practice, but was more likely in patients with listed risk factors (adjusted odds ratio [OR] = 4.62, 95% confidence intervals [CI] = 2.89-7.37) and in men (OR = 1.64, 95% CI = 1.07-2.52), and less likely in older age groups (age < or = 64 years = 1.00; 65-74 years = 0.47, 95% CI = 0.27-0.81; 75+ years = 0.34, 95% CI = 0.20-0.60). Of patients with listed risk factors, 27% could not recall having received any advice, and recall varied with medical condition. Only 40% of patients with reported high blood pressure recalled being given advice about salt. Those who recalled advice were more likely to report a healthier current lifestyle. Of those with unhealthy lifestyles, 30-50% were unaware that their lifestyle was unhealthy. CONCLUSION: Lifestyle advice is not recalled for some important risk factors, and some patients are unaware of their unhealthy lifestyle. Although advice is being preferentially targeted to those with risk factors, women and older patients recall advice less. Research is needed to assess the cost-effectiveness of advice for both sexes and different ages.
PMCID: PMC1313532  PMID: 10885085
2.  Identification of depression in diabetes: the efficacy of PHQ-9 and HADS-D 
The British Journal of General Practice  2010;60(575):e239-e245.
Background
Clinical guidelines advise screening for depression in patients with diabetes. The Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) are commonly used in primary care.
Aim
To compare the efficacy of HADS-D and PHQ-9 in identifying moderate to severe depression among primary care patients with type 2 diabetes.
Design of study
Self-report postal survey, clinical records assessed by GPs.
Setting
Seven metropolitan and rural general practices in Victoria, Australia.
Method
Postal questionnaires were sent to all patients with diabetes on the registers of seven practices in Victoria. A total of 561 completed postal questionnaires were returned, giving a response rate 47%. Surveys included demographic information, and history of diabetes and depression. Participants completed both the PHQ-9 and HADS-D. Clinical data from patient records included glycosylated hemoglobin (HbA1c) levels and medications.
Results
The proportion of the total sample completing HADS-D was 96.8% compared with 82.4% for PHQ-9. Level of education was unrelated to responses on the HADS-D but was related to completion of the PHQ-9. Using complete data (n = 456) from both measures, 40 responders showed HADS-D scores in the moderate to severe range, compared with 103 cases identified by PHQ-9. Only 35 cases were classified in the moderate to severe category by both the PHQ-9 and HADS-D. Items with the highest proportions of positive responses on the PHQ-9 were related to tiredness and sleeping problems and, on the HADS-D, feeling slowed down.
Conclusion
It may be that the items contributing to the higher prevalence of moderate to severe depression using the PHQ-9 are due to diabetes-related symptoms or sleep disorders.
doi:10.3399/bjgp10X502128
PMCID: PMC2880765  PMID: 20529487
depression; diabetes; Hospital Anxiety and Depression Scale; Patient Health Questionnaire; sleep disturbance
3.  Effect of lifestyle intervention for people with diabetes or prediabetes in real-world primary care: propensity score analysis 
BMC Family Practice  2011;12:95.
Background
Many lifestyle interventions for patients with prediabetes or type 2 diabetes mellitus (T2DM) have been investigated in randomised clinical trial settings. However, the translation of these programmes into primary care seems challenging and the prevalence of T2DM is increasing. Therefore, there is an urgent need for lifestyle programmes, developed and shown to be effective in real-world primary care. We evaluated a lifestyle programme, commissioned by the Dutch government, for patients with prediabetes or type 2 diabetes in primary care.
Methods
We performed a retrospective comparative medical records analysis using propensity score matching. Patients with prediabetes or T2DM were selected from ten primary healthcare centres. Patients who received the lifestyle intervention (n = 186) were compared with a matched group of patients who received usual care (n = 2632). Data were extracted from the electronic primary care records. Propensity score matching was used to control for confounding by indication. Outcome measures were exercise level, BMI, HbA1c, fasting glucose, systolic and diastolic blood pressure, total cholesterol, HDL and LDL cholesterol and triglycerides and the follow-up period was one year.
Results
There was no significant difference at follow-up in any outcome measure between either group. The reduction at one year follow-up of HbA1c and fasting glucose was positive in the intervention group compared with controls, although not statistically significant (-0.12%, P = 0.07 and -0.17 mmol/l, P = 0.08 respectively).
Conclusions
The effects of the lifestyle programme in real-world primary care for patients with prediabetes or T2DM were small and not statistically significant. The attention of governments for lifestyle interventions is important, but from the available literature and the results of this study, it must be concluded that improving lifestyle in real-world primary care is still challenging.
doi:10.1186/1471-2296-12-95
PMCID: PMC3180644  PMID: 21914190
4.  Provision of Counseling on Diabetes Self-Management: Are There Any Age Disparities? 
Patient education and counseling  2010;85(2):133-139.
OBJECTIVE
To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas.
METHODS
EMR search from 13 primary care clinics on patients aged ≥18 years (n=1300) who had been diagnosed with type 2 diabetes.
RESULTS
There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR=0.60; 95% CI=0.37–0.98). The mean HbA1c for patients aged ≥75 and 65–74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P<.001).
CONCLUSION
While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults.
PRACTICE IMPLICATIONS
Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population.
doi:10.1016/j.pec.2010.08.004
PMCID: PMC3021766  PMID: 20863646
Age-related disparities; health disparities; type 2 diabetes
5.  Epilepsy monitoring and advice recorded: general practitioners' views, current practice and patients' preferences. 
BACKGROUND: Epilepsy is a common condition that is managed at the interface between primary and secondary care. AIM: A study aimed to describe general practitioners' criteria for aspects of optimal epilepsy care and their estimates of current levels of care achieved; to compare these estimates with clinical data extracted from their patients' medical records; and to compare general practitioners' estimates and recorded data with information provided by the patients themselves. METHOD: Thirty seven general practitioners from six practices in the south Thames region were sent a questionnaire enquiring about current practice with regard to general practitioner and specialist monitoring of patients with epilepsy and provision of advice, and about their criteria for the optimum levels of aspects of epilepsy care. Of patients aged over 15 years in the study practices, 0.6% were found to have active epilepsy; 283 of these 326 patients were sent a questionnaire enquiring about their epilepsy, the service and advice provided, and whether they required more information. Responses to the general practitioners' questionnaire and to the patients' questionnaire were compared and also compared with information extracted from the patients' medical records. RESULTS: Ninety five per cent of the general practitioners responded. Of 255 patient questionnaires (90%) returned, 251 could be analysed. Of 247 patients, 168 (68%) reported having had no seizure in the previous six months. Forty of 241 patients (17%) had a regular arrangement to see their general practitioner regarding their epilepsy. Of 191 patients who expressed a preference, 116 (61%) reported preferring to receive their epilepsy care mainly from their general practitioner. General practitioners reported that ideally patients should be monitored in primary care every six months (the median recorded frequency was 14 months) and that there should be a record of advice given to all patients on driving, adverse effects of antiepileptic drugs, and self-help groups. Advice was recorded in patients' records as having been given on driving (46% of records), adverse effects of antiepileptic drugs (9%), and self-help groups (3%); 82 of 237 patients (35%) reported not receiving enough advice. CONCLUSION: Patients generally preferred to receive their epilepsy care in general practice. Monitoring and provision of advice were less than optimal from both the general practitioners' and the patients' point of view. New resources and skills will be necessary to bridge this perceived gap. Specially trained nurses may have a role in this monitoring and advice provision.
PMCID: PMC1239504  PMID: 8745845
6.  Patients' perspectives on foot complications in type 2 diabetes: a qualitative study 
Background
Foot ulceration is a major health problem for people with diabetes. To minimise the risk of ulceration, patients are advised to perform preventive foot self-care.
Aim
To explore beliefs about diabetic foot complications and everyday foot self-care practices among people with type 2 diabetes.
Design of study
Qualitative study using one-to-one interviews.
Setting
A suburban primary care health centre.
Method
Semi-structured interviews with a purposive sample of adults with type 2 diabetes but with no experience of foot ulceration.
Results
Most participants were unsure of what a foot ulcer is and unaware of the difficulties associated with ulcer healing. Prevention of accidental damage to the skin was not considered a priority, as few participants knew that this is a common cause of foot ulceration. Although it was recognised that lower-limb amputation is more common in people with diabetes, this was perceived to be predominantly caused by poor blood supply to the feet and unrelated to foot ulceration. Therefore, preventive foot care focused on stimulating blood circulation, for example by walking barefoot. Consequently, some of the behaviours participants considered beneficial for foot health could potentially increase the risk of ulceration. In some cases the uptake of advice regarding preventive foot care was hampered because participants found it difficult to communicate with health professionals.
Conclusion
Patients with type 2 diabetes may have beliefs about foot complications that differ from medical evidence. Such illness beliefs may play a role in foot-related behaviours that have previously been unrecognised. Health professionals need to explore and address the beliefs underlying patients' foot self-care practices.
doi:10.3399/bjgp08X319657
PMCID: PMC2566520  PMID: 18682014
diabetes mellitus; foot complications; foot self-care; illness beliefs; ulcer prevention
7.  A survey of diabetes care in general practice in Northern Ireland. 
The Ulster Medical Journal  2002;71(1):10-16.
We aimed to describe some key features of diabetes care carried out in primary care settings in Northern Ireland using a descriptive postal questionnaire survey sent to every general practice in Northern Ireland. 252 (70%) of practices responded. Of these 92% of practices have active registers of people with diabetes, identifying 1.9% of their population as having diabetes and 85% of practices use these registers for call/recall visits. Seventy five per cent of practices held diabetes clinics run by the general practitioner and nurse (63%) or a nurse alone (32%). Only 47% of practices felt they received adequate support from the acute diabetes team; with 29% meeting with them this team regularly and only 19% having a shared care protocol. Overall practices provided most of the routine care for 60% of their diabetic patients. The majority of GPs and practice nurses had received some diabetes education in the previous year. There has been a considerable change in the delivery of routine diabetes care in Northern Ireland. A large proportion of diabetes care now takes place in the community, much of it delivered by practice nurses. The organisational infrastructure necessary for the delivery of care is in place. Many practices have special interest in diabetes but the survey highlights a need for better communication and cooperation with secondary care. General practitioners recognise their educational needs in diabetes. They should also be aware of their practice nurses' needs, which should be addressed. There should be initiatives to improve the primary-secondary care interface in Northern Ireland.
PMCID: PMC2475362  PMID: 12137157
8.  Overall quality of diabetes care in a defined geographic region: different sides of the same story 
Background
In diabetes care, knowledge about what is achievable in primary and secondary care is important. There is a need for an objective method to assess the quality of care in different settings. A quality-of-care summary score has been developed based on process and outcome measures. An adapted version of this score was used to evaluate diabetes management in different settings.
Aim
To evaluate the quality of diabetes management in primary and secondary care in a defined geographic region in the Netherlands, using a quality score.
Design of study
Cross-sectional study.
Setting
Thirty general practices in the Netherlands.
Method
A study of 2042 patients with type 2 diabetes (1640 primary care and 402 secondary care) was conducted. Quality of diabetes management was assessed by a score of process and outcome indicators (range 0–40). Clustering at practice level and differences in patient characteristics (case mix) were taken into account.
Results
At the outpatient clinic, patients were younger (mean age 64.1 years, standard deviation (SD) = 12.5 years, versus mean age 67.1 years, SD = 11.7, P<0.001), had more diabetes-related complications (macrovascular: 39.7% versus 24.3%, P<0.001; and microvascular: 25.9% versus 7.3%, P<0.001), and lower quality-of-life scores (EuroQol-5D: mean = 0.60, SD = 0.29, versus mean = 0.80, SD = 0.21, P<0.001). After adjusting for case mix and clustering, there was a weak association between the setting of treatment and haemoglobin A1c (primary care: mean 7.1%, SD = 1.1, versus secondary care: mean 7.6%, SD = 1.2, P<0.016), and between setting and systolic blood pressure (primary: mean 145.7 mmHg, SD = 19.2, versus secondary care: 147.77 mmHg, SD 21.0, P<0.035). Quality-of-care summary scores in primary and secondary care differed significantly, with a higher score in primary care (mean 19.6, SD = 8.5 versus, mean 18.1, SD = 8.7, P<0.01). However, after adjusting for case mix and clustering, this difference lost significance.
Conclusion
GPs and internists are treating different categories of patients with type 2 diabetes. However, overall quality of diabetes management in primary and secondary care is equal. There is much room for improvement. Future guidelines may differentiate between different categories of patients.
doi:10.3399/bjgp08X280209
PMCID: PMC2435671  PMID: 18482488
case mix; hospital; medical staff, primary health care; quality of health care; type 2 diabetes mellitus
9.  Primary care nurses struggle with lifestyle counseling in diabetes care: a qualitative analysis 
BMC Family Practice  2010;11:41.
Background
Patient outcomes are poorly affected by lifestyle advice in general practice. Promoting lifestyle behavior change require that nurses shift from simple advice giving to a more counseling-based approach. The current study examines which barriers nurses encounter in lifestyle counseling to patients with type 2 diabetes. Based on this information we will develop an implementation strategy to improve lifestyle behavior change in general practice.
Method
In a qualitative semi-structured study, twelve in-depth interviews took place with nurses in Dutch general practices involved in diabetes care. Specific barriers in counseling patients with type 2 diabetes about diet, physical activity, and smoking cessation were addressed. The nurses were invited to reflect on barriers at the patient and practice levels, but mainly on their own roles as counselors. All interviews were audio-recorded and transcribed. The data were analyzed with the aid of a predetermined framework.
Results
Nurses felt most barriers on the level of the patient; patients had limited knowledge of a healthy lifestyle and limited insight into their own behavior, and they lacked the motivation to modify their lifestyles or the discipline to maintain an improved lifestyle. Furthermore, nurses reported lack of counseling skills and insufficient time as barriers in effective lifestyle counseling.
Conclusions
The traditional health education approach is still predominant in primary care of patients with type 2 diabetes. An implementation strategy based on motivational interviewing can help to overcome 'jumping ahead of the patient' and promotes skills in lifestyle behavioral change. We will train our nurses in agenda setting to structure the consultation based on prioritizing the behavior change and will help them to develop social maps that contain information on local exercise programs.
doi:10.1186/1471-2296-11-41
PMCID: PMC2889883  PMID: 20500841
10.  Patients with poorly controlled diabetes in primary care: healthcare clinicians' beliefs and attitudes 
Postgraduate Medical Journal  2006;82(967):347-350.
Objective
To determine doctors' and nurses' attitudes and beliefs about treating patients with type 2 diabetes with less than ideal glycaemic control while receiving maximal oral treatment in primary care.
Design
Focus groups.
Setting
Primary care.
Participants
Four focus groups of 23 GPs and practice nurses.
Results
General practice was thought to be the best setting for managing all patients with type 2 diabetes but there were concerns about a lack of resources and unfamiliarity with starting insulin. Issues around compliance were extensively discussed; the “failing diabetic” had dual meanings of failing glycaemic control and failing compliance and effort by both patient and doctor. Although views about insulin therapy differed, patients were understood to be resistant to starting insulin, representing for them a more serious stage of diabetes, with fears of needles and hypoglycaemia.
Conclusion
The role of diabetes specialist nurses working in primary care will be crucial in managing such patients to improve knowledge, for extra resources, for their experience of insulin use, and to change attitudes.
doi:10.1136/pgmj.2005.039545
PMCID: PMC2563795  PMID: 16679475
diabetes; primary care
11.  Patient Understanding of Diabetes Self-Management: Participatory Decision-Making in Diabetes Care 
Objective:
Our aim was to determine whether patient participation in decision-making about diabetes care is associated with understanding of diabetes self-management and subsequent self-care practices. We also identified issues that would impact messaging for use in mobile diabetes communication.
Research Design and Methods:
A cross-sectional observational study was conducted with type 2 diabetes patients (n = 81) receiving their care at the University of Maryland Joslin Diabetes Center. A convenience sample of patients were eligible to participate if they were aged 25–85 years, had type 2 diabetes, spoke English, and visited their physician diabetes manager within the past 6 months. In-person patient interviews were conducted at the time of clinic visits to assess patient understanding of diabetes management, self-care practices, and perceptions of participation in decision-making about diabetes care.
Results:
African Americans reported fewer opportunities to participate in decision-making than Caucasians, after controlling for education [mean difference (MD) = -2.4, p = .02]. This association became insignificant after controlling for patient–physician race concordance (MD = -1.5, p = .21). Patient understanding of self-care was predicted by having greater than high school education (MD = 3.6, p = .001) and having physicians who involved them in decision-making about their care. For each unit increase in understanding of diabetes self-care, the mean patient self-care practice score increased by 0.16 (p = .003), after adjustment for patient race and education.
Conclusions:
Patient participation in decision-making is associated with better understanding of care. Participation in decision-making plays a key role in patient understanding of diabetes self-management and subsequent self-care practices. Patients with limited education need specific instruction in foot care, food choices, and monitoring hemoglobin A1c.
PMCID: PMC3192639  PMID: 21722588
literacy; mobile; participatory; self-care
12.  Preventing diabetes-related morbidity and mortality in the primary care setting. 
Diabetes is the leading cause of blindness, end-stage renal failure, non-traumatic limb amputations, and cardiovascular morbidity and mortality. The vast majority of patients with diabetes receive routine care from primary care providers who are not endocrinologists. Primary care providers, including internists, family practice physicians, and physician extenders with advanced skills, face the important task of implementing standards of care recommendations for persons with diabetes. These recommendations draw upon an emerging body of compelling evidence regarding the prevention and management diabetes and its complications. The challenge of diabetes must be tackled on three fronts: Primary prevention, secondary prevention (of diabetes complications), and tertiary prevention (of morbidity and mortality from established complications). There is now abundant evidence that type 2 diabetes, which accounts for greater than 90% of diabetes world-wide, is preventable. Moreover, the complications of diabetes are preventable by a policy of tight glycemic control and comprehensive risk reduction. Even after complications have set in, intensive glucose control dramatically reduces the risk of progression of complications. The challenge, therefore, is the identification of strategies that enable translation of existing scientific data to pragmatic benefits. This article proposes 10 strategies for preventing or reducing diabetes-related morbidity and mortality at the primary care level. These strategies include provider education; patient empowerment through promotion of lifestyle and self-care practices; surveillance for microvascular complications; cardiovascular risk reduction; efficient use of medications; goal setting; and stratification of patients and triaging of those with poor glycemic control for more intensive management.
Images
PMCID: PMC2594314  PMID: 12126280
13.  Talking about smoking in primary care medical practice – Results of experimental studies from the US, UK and Germany 
Objective
To analyze effects of patient and physician characteristics on questions and advice about smoking in primary care practice and to examine country differences.
Methods
We conducted a factorial experiment, employing filmed scenarios in which actors played the role of patients with symptoms of coronary heart disease (CHD) or type 2 diabetes. Versions were filmed with patient-actors of different gender, age, race, and socioeconomic status. The videotapes were presented to primary care physicians in the US, UK and Germany. Physicians were asked whether they would ask questions about smoking or give cessation advice.
Resultst
Female and older CHD patients are less likely to be asked or get advice about smoking in all three countries. Effects of physician attributes are weak and inconsistent. Compared to physicians in the US and the UK, German doctors are least likely to ask questions or give advice.
Conclusions
Although all physicians viewed the same cases their questioning and advice giving differed according to patient attributes and country. Due to the experimental design external validity of the study may be limited.
Practice implications
Findings have implications for medical education and professional training of physicians as well as for the organization and financing of health care.
doi:10.1016/j.pec.2012.04.011
PMCID: PMC3444567  PMID: 22595655
primary care physicians; questions about smoking; cessation advice; comparative study
14.  Doctors’ and nurses’ views on patient care for type 2 diabetes: an interview study in primary health care in Oman 
Aim
This study aimed at exploring the experiences of primary health-care providers of their encounters with patients with type 2 diabetes, and their preferences and suggestions for future improvement of diabetes care.
Background
Barriers to good diabetes care could be related to problems from health-care providers’ side, patients’ side or the health-care system of the country. Treatment of patients with type 2 diabetes has become a huge challenge in Oman, where the prevalence has increased to high levels.
Method
Semi-structured interviews were conducted with 26 health-care professionals, 19 doctors and seven nurses, who worked in primary health care in Oman. Qualitative content analysis was applied.
Findings
Organizational barriers and barriers related to patients and health-care providers were identified. These included workload and lack of teamwork approach. Poor patients’ management adherence and influence of culture on their attitudes towards illness were identified. From the providers’ side, language barriers, providers’ frustration and aggressive attitudes towards the patients were reflected. Decreasing the workload, availability of competent teams with diabetes specialist nurses and continuity of care were suggested. Furthermore, changing professional behaviours towards a more patient-centred approach and need for health education to the patients, especially on self-management, were addressed. Appropriate training for health-care providers in communication skills with emphasis on self-care education and individualization of care according to each patient's needs are important for improvement of diabetes care in Oman.
doi:10.1017/S146342361200062X
PMCID: PMC3682753  PMID: 23259934
culture; Oman; patient–provider interaction; professional behaviour; qualitative content analysis
15.  Integrating Systematic Chronic Care for Diabetes into an Academic General Internal Medicine Resident-Faculty Practice 
Journal of General Internal Medicine  2008;23(11):1749-1756.
Background
The quality of care for diabetes continues to fall short of recommended guidelines and results. Models for improving the care of chronic illnesses advocate a multidisciplinary team approach. Yet little is known about the effectiveness of such models in an academic setting with a diverse patient population and resident physicians participating in clinical care.
Objective
To implement a chronic illness management (CIM) practice within an academic setting with part-time providers, and evaluate its impact on the completion of diabetes-specific care processes and on the achievement of recommended outcomes for patients with diabetes mellitus.
Design
Retrospective cohort study
Subjects
Patients with the diagnosis of diabetes mellitus who receive their primary care in an academic general internal medicine resident-faculty practice.
Measurements
Process and outcomes measures in patients exposed to the CIM practice were compared with non-exposed patients receiving usual care.
Main Results
Five hundred and sixty-five patients met inclusion criteria. Patients in the CIM practice experienced a significant increase in completion of care processes compared to control patients for measurement of annual low-density lipoprotein (LDL) cholesterol (OR 3.1, 95% CI 1.7–5.7), urine microalbumin (OR 3.3, 95% CI 2.1–5.5), blood pressure (OR 1.8, 95% CI 1.1–2.8), retinal examination (OR 1.9, 95% CI 1.3–2.7), foot monofilament examination (OR 4.2, 95% CI 3.0–6.1) and administration of pneumococcal vaccination (OR 5.2, 95% CI 3.0–9.3). CIM-exposed patients were also more likely to achieve improvements in clinical outcomes of glycemic and blood pressure control reflected by hemoglobin A1c less than 7.0% (OR 1.7, 95% CI 1.02–3) and blood pressure less than 130/80 (OR 2.8, 95% CI 2.1–4.5) compared to controls.
Conclusions
A systematic chronic care model can be successfully integrated into an academic general internal medicine practice and may result in improved processes of care and some clinical outcomes for diabetic patients. This study provides a model for further hypothesis generation and more rigorous testing of the quality benefits of structured chronic illness care in diverse outpatient practices.
doi:10.1007/s11606-008-0751-5
PMCID: PMC2585684  PMID: 18752028
diabetes; systematic chronic care; resident-faculty practice; chronic care model
16.  Individualized electronic decision support and reminders to improve diabetes care in the community: COMPETE II randomized trial 
Background
Diabetes mellitus is a complex disease with serious complications. Electronic decision support, providing information that is shared and discussed by both patient and physician, encourages timely interventions and may improve the management of this chronic disease. However, it has rarely been tested in community-based primary care.
Methods
In this pragmatic randomized trial, we randomly assigned adult primary care patients with type 2 diabetes to receive the intervention or usual care. The intervention involved shared access by the primary care provider and the patient to a Web-based, colour-coded diabetes tracker, which provided sequential monitoring values for 13 diabetes risk factors, their respective targets and brief, prioritized messages of advice. The primary outcome measure was a process composite score. Secondary outcomes included clinical composite scores, quality of life, continuity of care and usability. The outcome assessors were blinded to each patient’s intervention status.
Results
We recruited sequentially 46 primary care providers and then 511 of their patients (mean age 60.7 [standard deviation 12.5] years). Mean follow-up was 5.9 months. The process composite score was significantly better for patients in the intervention group than for control patients (difference 1.27, 95% confidence interval [CI] 0.79–1.75, p < 0.001); 61.7% (156/253) of patients in the intervention group, compared with 42.6% (110/258) of control patients, showed improvement (difference 19.1%, p < 0.001). The clinical composite score also had significantly more variables with improvement for the intervention group (0.59, 95% CI 0.09–1.10, p = 0.02), including significantly greater declines in blood pressure (−3.95 mm Hg systolic and −2.38 mm Hg diastolic) and glycated hemoglobin (−0.2%). Patients in the intervention group reported greater satisfaction with their diabetes care.
Interpretation
A shared electronic decision-support system to support the primary care of diabetes improved the process of care and some clinical markers of the quality of diabetes care. (ClinicalTrials.gov trial register no. NCT00813085.)
doi:10.1503/cmaj.081272
PMCID: PMC2704409  PMID: 19581618
17.  The use of insulin declines as patients live farther from their source of care: results of a survey of adults with type 2 diabetes 
BMC Public Health  2006;6:198.
Background
Although most diabetic patients do not achieve good physiologic control, patients who live closer to their source of primary care tend to have better glycemic control than those who live farther away. We sought to assess the role of travel burden as a barrier to the use of insulin in adults with diabetes
Methods
781 adults receiving primary care for type 2 diabetes were recruited from the Vermont Diabetes Information System. They completed postal surveys and were interviewed at home. Travel burden was estimated as the shortest possible driving distance from the patient's home to the site of primary care. Medication use, age, sex, race, marital status, education, health insurance, duration of diabetes, and frequency of care were self-reported. Body mass index was measured by a trained field interviewer. Glycemic control was measured by the glycosolated hemoglobin A1C assay.
Results
Driving distance was significantly associated with insulin use, controlling for the covariates and potential confounders. The odds ratio for using insulin associated with each kilometer of driving distance was 0.97 (95% confidence interval 0.95, 0.99; P = 0.01). The odds ratio for using insulin for those living within 10 km (compared to those with greater driving distances) was 2.29 (1.35, 3.88; P = 0.02).
Discussion
Adults with type 2 diabetes who live farther from their source of primary care are significantly less likely to use insulin. This association is not due to confounding by age, sex, race, education, income, health insurance, body mass index, duration of diabetes, use of oral agents, glycemic control, or frequency of care, and may be responsible for the poorer physiologic control noted among patients with greater travel burdens.
doi:10.1186/1471-2458-6-198
PMCID: PMC1557494  PMID: 16872541
18.  Insurance continuity and receipt of diabetes preventive care in a network of Federally Qualified Health Centers 
Medical care  2009;47(4):431-439.
Background and Objectives
Having health insurance is usually associated with better access to care and better health outcomes. For patients receiving care at Federally Qualified Health Centers (FQHCs), where care is provided regardless of insurance status, the role health insurance status plays in affecting receipt of services is less well understood.
Research Design
We used practice management data from a coalition of FQHCs in Oregon, and linked to Oregon’s electronic insurance data, to examine whether receipt of diabetes preventive care services was associated with continuity of insurance coverage among adult FQHC patients receiving diabetes care in 2005.
Results
About one-third (32%) of patients with diabetes received a flu vaccination in 2005, 36% an LDL screening, 54% at least one HbA1c screening, and 21% a nephropathy screening. Compared to the continuously insured, the continuously uninsured were less likely to receive an LDL screening, a flu vaccination, and/or a nephropathy screening; those with partial coverage were less likely than the continuously insured to receive a flu shot, at least one HbA1c screening, or an LDL screening.
Conclusions
Our results suggest that FQHCs do an excellent job in delivering most services to their uninsured and partially insured patients, but also underscore that for diabetic patients from underserved communities, having both an FQHC medical home and continuous health insurance plays a critical role in receiving optimal chronic disease management. Our study is one of the first to demonstrate how electronic administrative data from a network of FQHCs can be successfully used to gauge the state of healthcare delivery.
PMCID: PMC2730766  PMID: 19330890
diabetes care; safety net; health insurance
19.  The effectiveness of adding cognitive behavioural therapy aimed at changing lifestyle to managed diabetes care for patients with type 2 diabetes: design of a randomised controlled trial 
BMC Public Health  2007;7:74.
Background
In patients with type 2 diabetes, the risk for cardiovascular disease is substantial. To achieve a more favourable risk profile, lifestyle changes on diet, physical activity and smoking status are needed. This will involve changes in behaviour, which is difficult to achieve. Cognitive behavioural therapies focussing on self-management have been shown to be effective. We have developed an intervention combining techniques of Motivational Interviewing (MI) and Problem Solving Treatment (PST). The aim of our study is to investigate if adding a combined behavioural intervention to managed care, is effective in achieving changes in lifestyle and cardiovascular risk profile.
Methods
Patients with type 2 diabetes will be selected from general practices (n = 13), who are participating in a managed diabetes care system. Patients will be randomised into an intervention group receiving cognitive behaviour therapy (CBT) in addition to managed care, and a control group that will receive managed care only. The CBT consists of three to six individual sessions of 30 minutes to increase the patient's motivation, by using principles of MI, and ability to change their lifestyle, by using PST. The first session will start with a risk assessment of diabetes complications that will be used to focus the intervention.
The primary outcome measure is the difference between intervention and control group in change in cardiovascular risk score. For this purpose blood pressure, HbA1c, total and HDL-cholesterol and smoking status will be assessed. Secondary outcome measures are quality of life, patient satisfaction, physical activity, eating behaviour, smoking status, depression and determinants of behaviour change. Differences between changes in the two groups will be analysed according to the intention-to-treat principle, with 95% confidence intervals. The power calculation is based on the risk for cardiovascular disease and we calculated that 97 patients should be included in every group.
Discussion
Cognitive behavioural therapy may improve self-management and thus strengthen managed diabetes care. This should result in changes in lifestyle and cardiovascular risk profile. In addition, we also expect an improvement of quality of life and patient satisfaction.
Trial registration
Current Controlled Trials ISRCTN12666286
doi:10.1186/1471-2458-7-74
PMCID: PMC1876216  PMID: 17488511
20.  A comparative study of two various models of organising diabetes follow-up in public primary health care – the model influences the use of services, their quality and costs 
Background
In Finland diabetologists have long been concerned about the level of diabetes care as the incidence of type 1 diabetes and complicated type 2 diabetes is exceeding the capacity of specialist clinics. We compared the outcome of diabetes care in two middle-sized Finnish municipalities with different models of diabetes care organisation in public primary health care. In Kouvola the primary health care of all diabetic patients is based on general practitioners, whereas in Nurmijärvi the follow-up of type 1 and most complicated type 2 diabetic patients is assigned to a general practitioner specialised in diabetes care.
Methods
Our study population consisted of all adult diabetic patients living in the municipalities under review.
We compared the use and costs of public diabetes care, glycemic control, blood pressure, LDL-cholesterol level, the application of the national guidelines and patient satisfaction. The main outcome measures were the costs and use of health care services due to diabetes and its complications.
Results
In Nurmijärvi, where diabetes care was centralised, more type 1 diabetic patients were followed up in primary health care than in Kouvola, where general practitioners need more specialist consultations. The centralisation resulted in cost savings in the diabetes care of type 1 diabetic patients. Although the quality of care was similar, type 1 diabetic patients were more satisfied with their follow-up in the centralised system. In the care of type 2 diabetic patients the centralised system required fewer specialist consultations, but the quality and costs were similar in both models.
Conclusions
The follow-up of most diabetic patients – including type 1 diabetes – can be organised in primary health care with the same quality as in secondary care units. The centralised primary care of type 1 diabetes is less costly and requires fewer specialist consultations.
doi:10.1186/1472-6963-14-26
PMCID: PMC3907939  PMID: 24444378
Type 1 diabetes; Organisation of diabetes care; Costs of diabetes care; Patient satisfaction; Comparison of diabetes care; PHC diabetes care
21.  Effectiveness of and Adherence to Dietary and Lifestyle Counselling 
Objectives
The Nutritional Advice Protocol, established by the Department of Health to combat diabetes, has been implemented in primary health care throughout Oman since 2003. This study aimed to assess the effectiveness of dietary and lifestyle advice and determine the perception and attitudes of Omani adults with type 2 diabetes to diabetes management.
Methods
A cross-sectional epidemiological survey was conducted on 98 patients diagnosed with type 2 diabetes in Al-Buraimi Governorate, Oman. Metabolic parameters, dietary intake and exercise levels were evaluated in 2005 and re-evaluated in 2008.
Results
A total of 43% of the patients (male = 16, female = 27) had received no formal education. A significant reduction in fasting glucose and enhanced high density lipoprotein cholesterol were achieved in both male and female patients. However, in men, no changes were noted, other than in anthropometric and metabolic measurements and macronutrient intake. Conversely, women’s macronutrient intakes reduced significantly leading to considerable improvement in body weight, body mass index, blood glucose and total cholesterol levels. Eleven patients (11.6%) admitted that they did not adhere at all to the diet advised by the dietician; 63.2% (n = 62) reported they followed their diet sometimes, and 25.2% (n = 25) stated they strictly followed the diet.
Conclusion
Counselling largely illiterate diabetic patients about the impact of food, nutrition and exercise on diabetes shifted the patients from “Poor” to “Good” control in terms of metabolic outcome (glycosylated haemoglobin, fasting glucose and total cholesterol). This minor improvement could be further enhanced by more health education.
PMCID: PMC3074742  PMID: 21509254
Diabetes Mellitus; Type 2; Compliance; Diet therapy; Oman
22.  Cluster-Randomized Trial of a Mobile Phone Personalized Behavioral Intervention for Blood Glucose Control 
Diabetes Care  2011;34(9):1934-1942.
OBJECTIVE
To test whether adding mobile application coaching and patient/provider web portals to community primary care compared with standard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes.
RESEARCH DESIGN AND METHODS
A cluster-randomized clinical trial, the Mobile Diabetes Intervention Study, randomly assigned 26 primary care practices to one of three stepped treatment groups or a control group (usual care). A total of 163 patients were enrolled and included in analysis. The primary outcome was change in glycated hemoglobin levels over a 1-year treatment period. Secondary outcomes were changes in patient-reported diabetes symptoms, diabetes distress, depression, and other clinical (blood pressure) and laboratory (lipid) values. Maximal treatment was a mobile- and web-based self-management patient coaching system and provider decision support. Patients received automated, real-time educational and behavioral messaging in response to individually analyzed blood glucose values, diabetes medications, and lifestyle behaviors communicated by mobile phone. Providers received quarterly reports summarizing patient’s glycemic control, diabetes medication management, lifestyle behaviors, and evidence-based treatment options.
RESULTS
The mean declines in glycated hemoglobin were 1.9% in the maximal treatment group and 0.7% in the usual care group, a difference of 1.2% (P < 0.001) over 12 months. Appreciable differences were not observed between groups for patient-reported diabetes distress, depression, diabetes symptoms, or blood pressure and lipid levels (all P > 0.05).
CONCLUSIONS
The combination of behavioral mobile coaching with blood glucose data, lifestyle behaviors, and patient self-management data individually analyzed and presented with evidence-based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year.
doi:10.2337/dc11-0366
PMCID: PMC3161305  PMID: 21788632
23.  A Randomized Trial of Electronic Clinical Reminders to Improve Quality of Care for Diabetes and Coronary Artery Disease 
Objective: The aim of this study was to evaluate the impact of an integrated patient-specific electronic clinical reminder system on diabetes and coronary artery disease (CAD) care and to assess physician attitudes toward this reminder system.
Design: We enrolled 194 primary care physicians caring for 4549 patients with diabetes and 2199 patients with CAD at 20 ambulatory clinics. Clinics were randomized so that physicians received either evidence-based electronic reminders within their patients' electronic medical record or usual care. There were five reminders for diabetes care and four reminders for CAD care.
Measurements: The primary outcome was receipt of recommended care for diabetes and CAD. We created a summary outcome to assess the odds of increased compliance with overall diabetes care (based on five measures) and overall CAD care (based on four measures). We surveyed physicians to assess attitudes toward the reminder system.
Results: Baseline adherence rates to all quality measures were low. While electronic reminders increased the odds of recommended diabetes care (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.01–1.67) and CAD (OR 1.25, 95% CI 1.01–1.55), the impact of individual reminders was variable. A total of three of nine reminders effectively increased rates of recommended care for diabetes or CAD. The majority of physicians (76%) thought that reminders improved quality of care.
Conclusion: An integrated electronic reminder system resulted in variable improvement in care for diabetes and CAD. These improvements were often limited and quality gaps persist.
doi:10.1197/jamia.M1788
PMCID: PMC1174888  PMID: 15802479
24.  A survey of diabetes care in general practice in England and Wales. 
BACKGROUND: The focus of care for people with diabetes has shifted from hospital to general practice. Many practices now offer diabetes care via dedicated mini-clinics, shared care schemes or opportunistically. There has never been a national survey of the organisation of diabetes care in general practice. AIM: To describe some key features of diabetes care in primary care in England and Wales. METHOD: Descriptive postal questionnaire survey to one in five (1873) randomly sampled general practices. RESULTS: Seventy per cent (1320) of practices responded. Of these, 96% had diabetes registers identifying 1.9% of their population as having diabetes; 71% held clinics run by a general practitioner (GP) and a nurse (64%) or a nurse alone (34%); 80% felt adequately supported; and 54% shared patient management protocols with the local secondary care team. Overall, practices provided most of the routine diabetes care for 75% of their diabetic patients. The majority of GPs and practice nurses had received some recent, albeit brief, diabetes education. CONCLUSION: A large proportion of diabetes care now takes place in the community, much of it delivered by practice nurses. The organisational infrastructure necessary for delivering good care is in place. Many practices have a special interest in diabetes with the majority feeling adequately supported by secondary care. However, there are concerns about the educational needs of those providing care. More work needs to be done to ensure seamless care across the primary-secondary care interface.
PMCID: PMC1313748  PMID: 10954934
25.  Increasing efficacy of primary care-based counseling for diabetes prevention: Rationale and design of the ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial 
Background
Studies have shown that lifestyle behavior changes are most effective to prevent onset of diabetes in high-risk patients. Primary care providers are charged with encouraging behavior change among their patients at risk for diabetes, yet the practice environment and training in primary care often do not support effective provider counseling. The goal of this study is to develop an electronic health record-embedded tool to facilitate shared patient-provider goal setting to promote behavioral change and prevent diabetes.
Methods
The ADAPT (Avoiding Diabetes Thru Action Plan Targeting) trial leverages an innovative system that integrates evidence-based interventions for behavioral change with already-existing technology to enhance primary care providers' effectiveness to counsel about lifestyle behavior changes. Using principles of behavior change theory, the multidisciplinary design team utilized in-depth interviews and in vivo usability testing to produce a prototype diabetes prevention counseling system embedded in the electronic health record.
Results
The core element of the tool is a streamlined, shared goal-setting module within the electronic health record system. The team then conducted a series of innovative, "near-live" usability testing simulations to refine the tool and enhance workflow integration. The system also incorporates a pre-encounter survey to elicit patients' behavior-change goals to help tailor patient-provider goal setting during the clinical encounter and to encourage shared decision making. Lastly, the patients interact with a website that collects their longitudinal behavior data and allows them to visualize their progress over time and compare their progress with other study members. The finalized ADAPT system is now being piloted in a small randomized control trial of providers using the system with prediabetes patients over a six-month period.
Conclusions
The ADAPT system combines the influential powers of shared goal setting and feedback, tailoring, modeling, contracting, reminders, and social comparisons to integrate evidence-based behavior-change principles into the electronic health record to maximize provider counseling efficacy during routine primary care clinical encounters. If successful, the ADAPT system may represent an adaptable and scalable technology-enabled behavior-change tool for all primary care providers.
Trial Registration
ClinicalTrials.gov Identifier NCT01473654
doi:10.1186/1748-5908-7-6
PMCID: PMC3274467  PMID: 22269066

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