Health care and health status and outcomes for patients with type 2 diabetes

OBJECTIVE: To evaluate access and utilization of medical care, and health status and outcomes that would be influenced by recent medical care, in a representative sample of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A national sample of 733 adults with type 2 diabetes was studied from 1991 to 1994 in the Third National Health and Nutrition Examination Survey. Structured questionnaires and clinical and laboratory assessments were used to determine the frequencies of physician visits, health insurance coverage, screening for diabetes complications, treatment for hyperglycemia, hypertension, and dyslipidemia; and the proportion of patients who met treatment goals and established criteria for health outcome measures including hyperglycemia, albuminuria, obesity, hypertension, and dyslipidemia. RESULTS: Almost all patients had 1 source of primary care (95%), 2 or more physician visits during the past year (88%), and health insurance coverage (91%). Most (76%) were treated with insulin or oral agents for their diabetes, and 45% of those patients taking insulin monitored their blood glucose at least once per day The patients were frequently screened for retinopathy (52%), hypertension (88%), and dyslipidemia (84%). Of those patients with hypertension, 83% were diagnosed and treated with antihypertensive agents and only 17% were undiagnosed or untreated; most of the patients known to have dyslipidemia were treated with medication or diet (89%). Health status and outcomes were less than optimal: 58% had HbA1c >7.0, 45% had BMI >30, 28% had microalbuminuria, and 8% had clinical proteinuria. Of those patients known to have hypertension and dyslipidemia, 60% were not controlled to accepted levels. In addition, 22% of patients smoked cigarettes, 26% had to be hospitalized during the previous year, and 42% assessed their health status as fair or poor. CONCLUSIONS: Rates of health care access and utilization, screening for diabetes complications, and treatment of hyperglycemia, hypertension, and dyslipidemia in type 2 diabetes are high; however, health status and outcomes are unsatisfactory. There are likely to be multiple reasons for this discordance, including intractability of diabetes to current therapies, patient self-care practices, physician medical care practices, and characteristics of U.S. health care systems.     

Diabetic patients' medication underuse, illness outcomes, and beliefs about antihyperglycemic and antihypertensive treatments

OBJECTIVE—The purpose of this study was to determine how patients’ beliefs about antihyperglycemic and antihypertensive medications relate to medication underuse and health status.RESEARCH DESIGN AND METHODS—In diabetic patients from an economically distressed region, we assessed perceived necessity and harmfulness for antihyperglycemic (n = 803) and antihypertensive (n = 573) medications, past year''s medication underuse, A1C, systolic blood pressure (SBP), and diastolic blood pressure (DBP).RESULTS—After correction for multiple analyses, multivariate models indicated that perceived need for antihyperglycemic medication was associated with being younger, being prescribed insulin, and being prescribed multiple medications. Concern about antihyperglycemic medications was associated with being younger, African American, dissatisfied with information received about medication, and of low health literacy. For antihypertensives, perceived necessity was associated with having numerous medical comorbidities and being dissatisfied with medication information; concern was associated with being younger, dissatisfied with information received about medication, and of low health literacy. Up to one-half of patients underused at least one of the types of medication; many of these patients attributed this underuse to cost. For both types of medications, concern was significantly associated with both cost-related and non–cost-related underuse, and antihypertensive concern was associated with higher SBP and DBP.CONCLUSIONS—Even after adjustment for economic factors, patients who are younger, African American, or of low health literacy are especially concerned about medication harmfulness, which is in turn associated with medication underuse and higher blood pressure. To enhance adherence and outcomes, interventions should address patients’ underlying concerns about potential adverse treatment effects and focus on both cultural factors and health literacy.Despite advances in pharmacotherapy and decades of intervention trials to improve diabetes self-management support, adherence to diabetes medication regimens remains suboptimal (1). However, adherence is an “overdetermined” behavior insofar as it is influenced by a diverse variety of demographic, psychosocial, and economic factors. In this study, we focus on one of the least studied of these factors, patients’ personal beliefs about their treatment, because this construct seems to be an adherence determinant in other illnesses and is potentially modifiable through educational and psychosocial interventions.On both conceptual and empirical bases, treatment beliefs can be subdivided into adherence-increasing beliefs about treatment necessity and advantages and adherence-reducing beliefs about treatment harmfulness, risks, and barriers. Various forms of these constructs seem to explain adherence variation across several prevalent chronic illnesses, including HIV infection (2), depressive disorder (3–5), and cardiovascular disease (6). Although beliefs also appear to play a role in diabetes adherence, this conclusion is based mainly on single items from scales designed to measure other constructs and other nonstandardized measures (7,8).The nature, intensity, and impact of medication beliefs may vary across sociodemographic subgroups. For example, lower-income patients may be more fatalistic about their likelihood of negative illness outcomes and, as a consequence, be less motivated to pursue aggressive management or “tight control” regimens (9–12). Researchers and clinicians are also increasingly concerned about variation in health care trust, perceived discrimination, and outcomes between African American and Caucasian patients (7). Potential variations in diabetes treatment perceptions may provide an important window into these disparities.In this current study, we examined diabetic patients’ beliefs about their medication necessity and potential harmfulness in an economically distressed community. Given the importance of hypertension management for diabetes care, we also studied diabetic patients’ beliefs about their antihypertensive medications if applicable. After analyzing covariation in beliefs and sociodemographic characteristics, we modeled multivariate associations among beliefs, nonadherence (due to either cost or other reasons), and key medical outcomes.     

Health insurance status and outcomes of critically ill obstetric patients: A prospective cohort study in Argentina

Purpose

In Argentina, uninsured patients receive public health care, and the insured receive private health care. Our aim was to compare different outcomes between critically ill obstetric patients from both sectors.

Methods

This is a prospective cohort, including pregnant/postpartum patients requiring admission to 1 intensive care unit in the public sector (uninsured) and 1 in the private (insured) from January 1, 2008, to September 30, 2011.

Results

A total of 151 patients were included in the study. In uninsured (n = 63) vs insured (n = 88) patients, Acute Physiology and Chronic Evaluation II (APACHE II) and Sequential Organ Failure Assessment scores were 11 ± 6.5 vs 8 ± 4 and 3 (2-7) vs 1 (0-2), respectively, and 84% vs 100% received prenatal care (P = .001 for all). Multiple organ dysfunction syndrome (MODS) was present in 32 (54%) uninsured vs 9 (10%) insured patients (P = .001), and acute respiratory distress syndrome developed in 18 (30.5%) of 59 vs 2(2%) of 88 (P = .001). Neonatal survival was 80% vs 96% (P = .003). Variables independently associated with the development of MODS were APACHE II (odds ratio, 1.30 [1.13-1.49]), referral from another hospital (odds ratio, 11.43 [1.86-70.20]), lack of health insurance (odds ratio 6.75 [2.17-20.09]), and shock (odds ratio 4.82 [1.54-15.06]). Three patients died, all uninsured.

Conclusions

Uninsured critically ill obstetric patients (public sector) were more severely ill on admission and experienced worse outcomes than insured patients (private sector). Variables independently associated with MODS were APACHE II, shock, referral from another hospital, and lack of insurance.     

Satisfaction with care among patients with diabetes in two public health care systems.

OBJECTIVES: We compared patient satisfaction among adults with diabetes treated in a Veterans Affairs (VA) health care system with the satisfaction of patients treated in a county-funded health care system. We also examined whether satisfaction differences reflected differences in the process of patient care. DESIGN: Cross-sectional telephone survey of patients recruited from outpatient clinics. SUBJECTS: Five hundred and thirty eight adults, including 310 patients from 4 VA clinics and 228 patients from 2 county clinics. MEASURES: Overall satisfaction with care and satisfaction with 6 separate dimensions of care were measured using the Employee Health Care Value Survey. RESULTS: VA patients were more satisfied than were county patients overall and with 5 of 6 dimensions of their care. These differences increased when we adjusted for patients' sociodemographic and clinical characteristics. VA patients reported more diabetes counseling and shorter waiting times to see their doctor. Each of these self-reported process measures was positively correlated with satisfaction and, when taken into account, reduced the differences in satisfaction between the two systems. However, even when we controlled both for patient characteristics and the process of care, VA patients still were more satisfied than were county patients with their care overall as well as with their access to care, communication with providers, and the quality of their health outcomes. CONCLUSIONS: In this study, VA patients with diabetes were more satisfied with their health care than were county patients. Perceived diabetes-related counseling and shorter waiting times contributed to differences between the systems in patient satisfaction but did not explain them completely.     

Determinants of medication underuse and medication overuse in patients with chronic non-malignant pain: A multicenter study

Background

In chronic non-malignant pain, medication is often used as an important cornerstone of the treatment. Medication non-adherence is a frequent problem in chronic conditions. In patients with chronic non-malignant pain, medication non-adherence ranges between 8% and 53%. Two types of non-adherence can be identified: underuse and overuse of pain medication.

Objective

To examine determinants of both medication underuse and overuse non-adherence in patients with chronic non-malignant pain, with a focus on factors related to all five categories of determinants of medication non-adherence simultaneously, as proposed by the WHO.

Design

A multicenter cross-sectional study.

Settings

Three multidisciplinary outpatient pain centers in Flanders, Belgium.

Participants

A total of 265 patients with chronic non-malignant pain participated in the study.

Methods

Medication non-adherence was assessed by a self-report interview. Associations of socio-economic, treatment related, condition related, patient related and health care system related factors with medication underuse or overuse were determined by building two separate multivariable binary logistic regression models.

Results

Thirty eight percent of the patients were fully adherent. Based on multivariable analyses, underuse was significantly associated with more prescribed analgesics (OR = 2.303), self-medication (OR = 4.679), lower pain intensity (OR = 0.821), active coping strategies (OR = 1.132) and lack of information (OR = 0.268). Overuse of medication was associated with more prescribed analgesics (OR = 1.645) and current smoking (OR = 2.744).

Conclusion

Patients underusing or overusing their medication do have a different risk profile. The set of determinants of non-adherence, proposed by WHO, is suitable to study determinants of underuse, but the framework is less suitable to study determinants of medication overuse.     

南昌市糖尿病患者社区护理需求调查及其影响因素分析

目的调查分析南昌市糖尿病患者社区护理需求现状及其影响因素。方法选取南昌市3个社区卫生服务中心的292例糖尿病患者作为调查对象,利用自制调查表进行调查。结果南昌市糖尿病患者社区护理总需求处于中等水平,得分为(3.99±0.19)分,患者对健康促进方面需求最高,并发症防护方面需求最低。从具体项目看,提供血糖、血压、肝、肾功能等的定期检查在糖尿病疾病护理方面需求最高,达100%;并发症防护方面,低血糖的预防宣教和紧急救护需求较高,占98.6%;健康促进方面,提供健康行为与生活方式指导的需求占96.9%。影响糖尿病患者对社区护理各方面需求的主要因素有糖尿病并发症状况、治疗方式、年龄及主要照顾对象等,其中有无并发症是影响糖尿病患者社区护理需求的重要因素。结论积极开展糖尿病社区护理须以患者需求为导向,根据影响需求的因素,切实在疾病护理、并发症防护和健康促进3方面拓展服务内容和完善服务模式。     

Managed care penetration,insurance status,and access to health care

BACKGROUND: Access to health care, reflected by an ability to meet one's health needs, is influenced by individual characteristics and the environment. Although managed care activity influences healthcare prices and overall utilization, its relationship to access and its broader effects across different insurance categories has not been well studied. OBJECTIVE: To examine the association between managed care activity and individuals' access to care, and to assess differences in this relationship by insurance status. RESEARCH DESIGN: Cross-sectional survey of households conducted in 1998. SUBJECTS: A sample of 15,613 adult Ohio residents. MEASURES: Self-reported difficulties in obtaining health care, medications, supplies, or medical equipment in the past year. RESULTS: A total of 1248 (8.0%) identified an access problem. In bivariate analyses, these problems were more common among continuously and intermittently uninsured individuals compared with those who were continuously insured during the previous 12 months (P<0.001) and also among those living in areas with more managed care (P=0.01). After accounting for other individual and environmental characteristics in hierarchical analyses, individuals residing in areas with more managed care had 28% higher odds of reporting problems obtaining care than those elsewhere (multivariate odds ratio, 1.28; 95% confidence interval, 1.04-1.58]; P=0.02). No significant interaction between managed care penetration and insurance status was observed. CONCLUSIONS: Greater managed care activity is associated with unfavorable patterns of healthcare access despite an individual's insurance status, suggesting more pervasive effects. Unintended effects should be carefully evaluated when formulating future programs that seek to address disparities in access to care.     

Congruence of three self-report measures of medication adherence among HIV patients

OBJECTIVE: To evaluate the accordance between three measures of self-reported medication adherence. METHODS: A survey was administered to HIV patients. The three adherence measures included a four-item Morisky-type scale (Measure1) and two measures defining adherence as the percentage of doses taken as prescribed during the past two days (Measure2) or past two weeks (Measure3). RESULTS: For Measure1, 29.2% of the patients were categorized as high adherence and 61.5% as medium adherence. For Measure2 and Measure3, the mean scores were 93.6% and 96.5%, respectively. Using 90% as cutoff values, 78.5% and 95.4% of the patients were classified as adherent by Measure2 and Measure3, respectively (kappa = 0.30; p = 0.001). When 80% was used, 90.8% of the patients were classified as adherent for Measure2 and 96.9% for Measure3 (kappa = 0.48; p < 0.001). When using 90% and 80% as cutoff values to categorize Measure2 and Measure3 as three levels, there was no agreement between Measure1 and the other two measures. The accordance of Measure2 and Measure3 was significant albeit not high (kappa = 0.31; p < 0.001). CONCLUSIONS: The accordance between a Morisky-type adherence scale and measures of missed doses is unsatisfactory. However, "missed-dose" measures using two-day or two-week time periods yield fairly similar results. Researchers should be cautious when comparing adherence rates between studies that use different methods for assessing adherence.     

Relationship of depression and diabetes self-care, medication adherence, and preventive care

OBJECTIVE: We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. RESEARCH DESIGN AND METHODS: In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. RESULTS: This predominantly type 2 diabetic population had a mean HbA(1c) level of 7.8 +/- 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA(1c) tests was 2.2 +/- 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m(2), and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 +/- 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients. CONCLUSIONS: In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.     

3例暴发性1型糖尿病患者的护理

总结3例暴发性1型糖尿病患者的护理体会,护理要点包括:严密观察患者意识、生命体征、液体出入量、电解质和酸碱平衡、血糖及各系统功能变化,配合医生抢救患者,并积极给予皮肤、口腔、会阴部护理,病情稳定后给予积极的糖尿病宣教和心理疏导.3例全部痊愈出院.