Diabetes in the managed care setting: a prospective plan.

BACKGROUND: As managed care organizations (MCOs) continue to expand into the care of the chronically ill, the concept of providing cost-effective care with a preventive approach is vital for primary care providers (PCPs) to embrace. Diabetes is an ideal disease to incorporate this concept. METHODS: We reviewed the literature using MEDLINE. We used the American Diabetes Association (ADA) Provider Recognition Program guidelines as the foundation for MCOs to establish a diabetes disease management program. RESULTS: The implementation of disease management protocols, the use of computerized management systems, and the team approach can provide cost-effective diabetic care. CONCLUSIONS: To compete in the managed care market, it is vital for providers to link with their Independent Practice Associations (IPA), the ADA, and MCOs to implement standard protocols and negotiate for adequate reimbursement.     

Diabetes guidelines: a summary and comparison of the recommendations of the American Diabetes Association, Veterans Health Administration, and American Association of Clinical Endocrinologists

OBJECTIVE: This paper summarizes and compares 3 major organizations' guidelines for the management of diabetes mellitus. BACKGROUND: Diabetes mellitus is a chronic disease that affects >16 million Americans. A decrease in adverse events has been demonstrated when hyperglycemia and comorbid conditions such as hypertension and dyslipidemia are controlled in patients with diabetes. Although each patient with diabetes is unique and medical care should be tailored to his or her individual needs, clinical evidence and expert opinion have established a baseline level of care for all patients with diabetes. Guidelines have been created to guide practitioners in selecting appropriate care, but their length and complexity may serve as barriers to their use. METHODS: The diabetes management guidelines of the American Diabetes Association (ADA), Veterans Health Administration (VA), and American Association of Clinical Endocrinologists (AACE) are summarized and compared in both text and tabular form. CONCLUSION: Although the guidelines published by the ADA, VA, and AACE vary slightly, all of them can be used to ensure that patients with diabetes receive appropriate care.     

Adherence to American Diabetes Association standards of care by rural health care providers

OBJECTIVE: To determine whether rural health care providers are compliant with American Diabetes Association (ADA) clinical practice guidelines for glycemic, blood pressure, lipid management, and preventative services. RESEARCH DESIGN AND METHODS: This study was performed using a retrospective chart review of 399 patients 45 years of age and older, with a definitive diagnosis of diabetes seen for primary diabetes care at four rural health facilities in Montana between 1 January 1999 and 1 August 2000. RESULTS: Glycemic testing was adequate (85%), and glycemic control (HbA(1c) 7.43 +/- 1.7%) was above the national average. Comorbid conditions of hypertension and dyslipidemia were not as well managed. Mean systolic blood pressure (SBP) was 139 +/- 18.8 mmHg and LDL was 119 +/- 33 mg/dl. Of 399 patients, 11 were considered as needing no additional treatment based on ADA guidelines of an HbA(1c) level <7%, a BP <130/85 mmHg, and a LDL level <100 mg/dl. Monofilament testing and dilated eye examinations were poorly documented, as were immunizations. There were few referrals for diabetic education. CONCLUSIONS: Rural health care practitioners are not adequately following the ADA standards for comprehensive management of their patients with diabetes. Glycemic testing is being ordered, but HbA(1c) values indicate that patients do not have their diabetes under optimal control. The comorbid conditions of hypertension and dyslipidemia are not optimally managed according to the ADA guidelines.     

PS1-35: Impact of an ADA-Accredited Diabetes Education on Healthcare Utilization

Background/Aims Diabetes self-management education delivered by certified diabetes educators (CDE) can improve persons' self-management skills, self-efficacy for managing their diabetes, and clinical outcomes among patients with Type II diabetes. In addition, these education programs have the potential to reduce healthcare utilization, costs, and disabilities associated with the disease. Objective The purpose of this study was to measure the impact of Type 2 Diabetes BASICS education program (obtained from the International Diabetes Center in Minneapolis) on healthcare utilization among Scott & White SeniorCare members. The Diabetes Education site at Scott & White is nationally certified by the American Diabetes Association (ADA). Methods This was a retrospective cohort study of participants who attended the education program at a single program delivery site. Subjects were program participants who attended four BASICS class sessions over a six months period between January 2005 and July 2010 and were also enrolled in a Medicare Cost Contract product. About 349 subjects were included in the analysis. The key outcome variables were number of outpatient visits, number of inpatient hospitalization and length of inpatient stay. Differences in average number of outpatient visits, number of inpatient hospitalization, and length of inpatient stay were compared for the 12-months before participants began the education program and the 12-months after the completion. The unadjusted men differences were calculated using paired t-test. Adjusted mean difference in outpatient utilization was estimated from a linear regression and inpatient utilization by negative binomial regression adjusting for patient's age and gender. Results On average, the number of outpatient visits decreased from 8.38 in the year before participants began the program to 7.70 (p=0.04) in the year after they finished the program. In addition, the unadjusted mean number of inpatient admissions per year was significantly reduced from 0.34 to 0.20(p=0.02). The adjusted mean difference in outpatient visits decreased by 0.72 (p<0.001), however, no significant difference was observed for adjusted inpatient utilization. Discussion Health plan members who participated in the ADA-certified diabetes education class showed significant reductions in both outpatient and inpatient health service utilization in the year following class participation compared to the year before their participation.     

Competing demands for time and self-care behaviors, processes of care, and intermediate outcomes among people with diabetes: Translating Research Into Action for Diabetes (TRIAD)

OBJECTIVE

To determine whether competing demands for time affect diabetes self-care behaviors, processes of care, and intermediate outcomes.

RESEARCH DESIGN AND METHODS

We used survey and medical record data from 5,478 participants in Translating Research Into Action for Diabetes (TRIAD) and hierarchical regression models to examine the cross-sectional associations between competing demands for time and diabetes outcomes, including self-management, processes of care, and intermediate health outcomes.

RESULTS

Fifty-two percent of participants reported no competing demands, 7% reported caregiving responsibilities only, 36% reported employment responsibilities only, and 6% reported both caregiving and employment responsibilities. For both women and men, employment responsibilities (with or without caregiving responsibilities) were associated with lower rates of diabetes self-care behaviors, worse processes of care, and, in men, worse HbA_1c.

CONCLUSIONS

Accommodations for competing demands for time may promote self-management and improve the processes and outcomes of care for employed adults with diabetes.Diabetes self-management entails a complex set of health behaviors. For people living with young children or dependent adults and for those who work outside the home, caregiving responsibilities and/or expectations in the workplace may be barriers to self-management (1).We conducted a cross-sectional analysis using data from Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care, to assess whether there are associations between competing demands for time and diabetes self-care behaviors, processes of care, and intermediate health outcomes.     

Best practice in the assessment and management of diabetic foot ulcers.

Diabetes is an increasingly serious health issue in the rehabilitation population. Foot ulcers develop in approximately 15% of people with diabetes and are a preceding factor in approximately 85% of lower limb amputations. Nurses have significant opportunity to positively influence client outcomes and quality of life by promoting maintenance of healthy feet, identifying emerging problems, and supporting evidence-based self-care and interdisciplinary intervention. Best practice guidelines (BPG), such as those developed by the Registered Nurses Association of Ontario, provide a framework to enhance nursing practice and promote excellence in client care. This article highlights key evidence from the BPG, "Assessment and Management of Foot Ulcers for People with Diabetes," and other relevant diabetes literature. This information better equips rehabilitation nurses to promote ulcer prevention strategies; identifies key factors in ulcer risk; and utilizes current, best evidence for ulcer assessment, management, and evaluation.     

Testing a conceptual framework for diabetes self-care management

Diabetes is a major source of morbidity, mortality, and economic expense in the United States. The majority of researchers and clinicians believe that diabetes is a self-care management disease, and that patients should be reliable, capable, and sufficiently responsible to take care of themselves. However, individuals with diabetes may or may not have diabetes knowledge, social support, self-care agency (an individual's capability to perform self-care actions), and self-efficacy (an individual's beliefs in his or her capability to perform self-care actions) that would help them to engage in diabetes self-care management. Therefore, this study examined the relationship among those factors using a cross-sectional model testing design. A convenient sample of 141 insulin-requiring individuals with either diabetes type 1 or type 2, 21 years old and over, was recruited from an outpatient diabetes care center located in a Southeast region of the United States. Simple linear regression, multiple standard regression, and multiple hierarchical regression were used to analyze the data. Individuals with greater diabetes knowledge had greater self-care agency and self-efficacy. Those with a higher score in social support had greater self-care agency and better diabetes self-care management, and those with greater self-efficacy had better diabetes self-care management. In addition, self-care agency mediated the effects of diabetes knowledge on self-efficacy and the effects of social support on diabetes self-care management. Self-efficacy mediated the effects of self-care agency on diabetes self-care management. Furthermore, the linear combination of diabetes knowledge, social support, self-care agency, and self-efficacy, taken together, positively affected diabetes self-care management. Enhancing an individual's diabetes knowledge, social support, self-care agency, and self-efficacy may be a strategy which can promote better engagement in diabetes self-care.     

Integrating medical management with diabetes self-management training: a randomized control trial of the Diabetes Outpatient Intensive Treatment program

OBJECTIVE: This study evaluated the Diabetes Outpatient Intensive Treatment (DOIT) program, a multiday group education and skills training experience combined with daily medical management, followed by case management over 6 months. Using a randomized control design, the study explored how DOIT affected glycemic control and self-care behaviors over a short term. The impact of two additional factors on clinical outcomes were also examined (frequency of case management contacts and whether or not insulin was started during the program). RESEARCH DESIGN AND METHODS: Patients with type 1 and type 2 diabetes in poor glycemic control (A1c >8.5%) were randomly assigned to DOIT or a second condition, entitled EDUPOST, which was standard diabetes care with the addition of quarterly educational mailings. A total of 167 patients (78 EDUPOST, 89 DOIT) completed all baseline measures, including A1c and a questionnaire assessing diabetes-related self-care behaviors. At 6 months, 117 patients (52 EDUPOST, 65 DOIT) returned to complete a follow-up A1c and the identical self-care questionnaire. RESULTS: At follow-up, DOIT evidenced a significantly greater drop in A1c than EDUPOST. DOIT patients also reported significantly more frequent blood glucose monitoring and greater attention to carbohydrate and fat contents (ACFC) of food compared with EDUPOST patients. An increase in ACFC over the 6-month period was associated with improved glycemic control among DOIT patients. Also, the frequency of nurse case manager follow-up contacts was positively linked to better A1c outcomes. The addition of insulin did not appear to be a significant contributor to glycemic change. CONCLUSIONS: DOIT appears to be effective in promoting better diabetes care and positively influencing glycemia and diabetes-related self-care behaviors. However, it demands significant time, commitment, and careful coordination with many health care professionals. The role of the nurse case manager in providing ongoing follow-up contact seems important.     

A nurse-managed diabetes care programme

AIMS: To compare diabetes outcomes in patients under endocrinologist-directed diabetes care with those in patients in a nurse-managed diabetes care (NMDC) programme. METHODS: NMDC was provided to the diabetic patients referring to a Wednesday diabetes clinic in Shiraz. A total of 159 patients who had received such care were hierarchically matched with 159 diabetic patients receiving usual endocrinologist care in the same clinic during the rest of the week. Outcomes in patients who completed 1 year under NMDC were compared with those of usual endocrinologist care patients and also with those derived from the year before receiving NMDC. RESULTS: For patients in NMDC programme, the process measures recommended by the American Diabetes Association (ADA) were carried out more frequently than for the appropriate control patients. Under NMDC, HbA(1c) levels fell 3.2% in the 117 patients who were followed for at least 6 months, when compared with a 2.5% fall under usual endocrinologist care (p < 0.001). During the year before the study, in 73 patients mean HbA(1c) levels decreased by 2.6%. At the end of a year under the NMDC programme, the values fell further by 0.65% (p < 0.001). Also, the proportions of patients with TG levels > 150 mg% and LDL levels > 100 mg% decreased from 31% and 36% to 16% and 20%, respectively (p < 0.04 and p < 0.05, respectively). CONCLUSION: NMDC programme improves diabetes outcomes more significantly than endocrinologist-directed care.     

Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits

OBJECTIVE: To evaluate the effectiveness of a cluster visit model led by a diabetes nurse educator for delivering outpatient care management to adult patients with poorly controlled diabetes. RESEARCH DESIGN AND METHODS: This study involved a randomized controlled trial among patients of Kaiser Permanente's Pleasanton, CA, center who were aged 16-75 years and had either poor glycemic control (HbA1c > 8.5%) or no HbA1c test performed during the previous year. Intervention subjects received multidisciplinary outpatient diabetes care management delivered by a diabetes nurse educator, a psychologist, a nutritionist, and a pharmacist in cluster visit settings of 10-18 patients/month for 6 months. Outcomes included change (from baseline) in HbA1c levels; self-reported changes in self-care practices, self-efficacy, and satisfaction; and utilization of inpatient and outpatient health care. RESULTS: After the intervention, HbA1c levels declined by 1.3% in the intervention subjects versus 0.2% in the control subjects (P < 0.0001). Several self-care practices and several measures of self-efficacy improved significantly in the intervention group. Satisfaction with the program was high. Both hospital (P = 0.04) and outpatient (P < 0.01) utilization were significantly lower for intervention subjects after the program. CONCLUSIONS: A 6-month cluster visit group model of care for adults with diabetes improved glycemic control, self-efficacy, and patient satisfaction and resulted in a reduction in health care utilization after the program.     

Evaluation of a nurse-care management system to improve outcomes in patients with complicated diabetes

OBJECTIVE: This study evaluated the efficacy of a nurse-care management system designed to improve outcomes in patients with complicated diabetes. RESEARCH DESIGN AND METHODS: In this randomized controlled trial that took place at Kaiser Permanente Medical Center in Santa Clara, CA, 169 patients with longstanding diabetes, one or more major medical comorbid conditions, and HbA(lc) >10% received a special intervention (n = 84) or usual medical care (n = 85) for 1 year. Patients met with a nurse-care manager to establish individual outcome goals, attended group sessions once a week for up to 4 weeks, and received telephone calls to manage medications and self-care activities. HbA(lc), LDL, HDL, and total cholesterol, triglycerides, fasting glucose, systolic and diastolic blood pressure, BMI, and psychosocial factors were measured at baseline and 1 year later. Annualized physician visits were determined for the year before and during the study. RESULTS: At 1 year, the mean reductions in HbA(lc), total cholesterol, and LDL cholesterol were significantly greater for the intervention group compared with the usual care group. Significantly more patients in the intervention group met the goals for HbA(1c) (<7.5%) than patients in usual care (42.6 vs. 24.6%, P < 0.03, chi(2)). There were no significant differences in any of the psychosocial variables or in physician visits. CONCLUSIONS: A nurse-care management program can significantly improve some medical outcomes in patients with complicated diabetes without increasing physician visits.     

Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria

OBJECTIVE: Little is known about the impact of disease management programs on medical costs for patients with diabetes. This study compared health care costs for patients who fulfilled health employer data and information set (HEDIS) criteria for diabetes and were in a health maintenance organization (HMO)-sponsored disease management program with costs for those not in disease management. RESEARCH DESIGN AND METHODS: We retrospectively examined paid health care claims and other measures of health care use over 2 years among 6,799 continuously enrolled Geisinger Health Plan patients who fulfilled HEDIS criteria for diabetes. Two groups were compared: those who were enrolled in an opt-in disease management program and those who were not enrolled. We also compared HEDIS data on HbA(1c) testing, percent not in control, lipid testing, diabetic eye screening, and kidney disease screening. All HEDIS measures were based on a hybrid method of claims and chart audits, except for percent not in control, which was based on chart audits only. RESULTS: Of 6,799 patients fulfilling HEDIS criteria for the diagnosis of diabetes, 3,118 (45.9%) patients were enrolled in a disease management program (program), and 3,681 (54.1%) were not enrolled (nonprogram). Both groups had similar male-to-female ratios, and the program patients were 1.4 years younger than the nonprogram patients. Per member per month paid claims averaged 394.62 dollars for program patients compared with 502.48 dollars for nonprogram patients (P < 0.05). This difference was accompanied by lower inpatient health care use in program patients (mean of 0.12 admissions per patient per year and 0.56 inpatient days per patient per year) than in nonprogram patients (0.16 and 0.98, P < 0.05 for both measures). Program patients experienced fewer emergency room visits (0.49 per member per year) than nonprogram patients (0.56) but had a higher number of primary care visits (8.36 vs. 7.78, P < 0.05 for both measures). Except for emergency room visits, these differences remained statistically significant after controlling for age, sex, HMO enrollment duration, presence of a pharmacy benefit, and insurance type. Program patients also achieved higher HEDIS scores for HbA(1c) testing as well as for lipid, eye, and kidney screenings (96.6, 91.1, 79.1, and 68.5% among program patients versus 83.8, 77.6, 64.9, and 39.3% among nonprogram patients, P < 0.05 for all measures). Among 1,074 patients with HbA(1c) levels measured in a HEDIS chart audit, 35 of 526 (6.7%) program patients had a level >9.5%, as compared with 79 of 548 (14.4%) nonprogram patients. CONCLUSIONS: In this HMO, an opt-in disease management program appeared to be associated with a significant reduction in health care costs and other measures of health care use. There was also a simultaneous improvement in HEDIS measures of quality care. These data suggest that disease management may result in savings for sponsored managed care organizations and that improvements in HEDIS measures are not necessarily associated with increased medical costs.     

The association of diabetes specialist care with health care practices and glycemic control in patients with type 1 diabetes: a cross-sectional analysis from the Pittsburgh epidemiology of diabetes complications study

OBJECTIVE: To determine whether diabetes care characteristics and glycemic control differ by use of specialist care in a representative cohort of patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Health care, sociodemographic characteristics, and glycemic control were compared between participants in the Pittsburgh Epidemiology of Diabetes Complications Study who reported receiving specialist care (n = 212) and those who did not (n = 217). Specialist care was defined as having received care from an endocrinologist or diabetologist or diabetes clinic attendance during the last year. RESULTS: Patients who reported receiving specialist care were more likely to be female, to have an education level beyond high school, to have an annual household income >$20,000, and to have health insurance. Additionally, patients receiving specialist care were more likely to have received diabetes education during the previous 3 years, to have knowledge of HbAlc testing and to have received that test during the previous 6 months, to have knowledge of the Diabetes Control and Complications Trial results, to self-monitor blood glucose, and to inject insulin more than twice daily. A lower HbA1 level was associated with specialist care versus generalist care (9.7 vs. 10.3%; P = 0.0006) as were higher education and income levels. Multivariate analyses suggest that the lower HbA1 levels observed in patients receiving specialist care were restricted to patients with an annual income >$20,000. CONCLUSIONS: Specialist care was associated with higher levels of participation in diabetes self-care practices and a lower HbA1 level. Future efforts should research and address the failure of patients with low incomes to benefit from specialist care.     

Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems.

OBJECTIVE: A controlled trial with 15-month follow-up was conducted in two outpatient clinics to study the effects of using the problem-based learning technique to implement a diabetes clinical practice guideline. RESEARCH DESIGN AND METHODS: A total of 144 patients with type 2 diabetes aged 25-65 years in two internal medicine outpatient clinics were enrolled in the study. African-Americans and Hispanics made up > 75% of the patients. Doctors and staff in one of the clinics were trained in the use of a clinical practice guideline based on Staged Diabetes Management. A problem-based learning educational program was instituted to reach consensus on a stepped intensification scheme for glycemic control and to determine the standards of care used in the clinic. HbA1c was obtained at baseline and at 9 and 15 months after enrollment. RESULTS: At 9 months, there was a mean -0.90% within-subject change in HbA1c in the intervention group, with no significant changes in the control group. The 15-month mean within-subject change in HbA1c of -0.62% in the intervention group was also significant. Among intervention patients, those with the poorest glycemic control at baseline realized the greatest benefit in improvement of HbA1c. The intervention group also exhibited significant changes in physician adherence with American Diabetes Association standards of care. CONCLUSIONS: Clinical practice guidelines are an effective way of improving the processes and outcomes of care for patients with diabetes. Problem-based learning is a useful strategy to gain physician support for clinical practice guidelines. More intensive interventions are needed to maintain treatment gains.     

Guidelines for glycemic control

Glycemic control in diabetes patients continues to evolve as new medications are introduced and clinical trial data become available. The American Diabetes Association (ADA) guidelines for 2004, for the first time, provide targets for both preprandial and postprandial glucose levels. The ADA, however, does not provide guidelines regarding specific medication therapy. This paper provides a detailed treatment algorithm that is easy to follow for nurse practitioners as well as primary care providers. Progress in our understanding of diabetes and new therapeutic agents will dictate modifications of treatment targets and guidelines, with the goal of making euglycemia achievable for all patients with diabetes.     

The national glycohemoglobin standardization program: a five-year progress report.

BACKGROUND: The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated conclusively that risks for complications in patients with diabetes are directly related to glycemic control, as measured by glycohemoglobin (GHB). In 1994, one year after the DCCT results were reported, the American Diabetes Association (ADA) set specific diabetes treatment goals. However, 1993 College of American Pathologists (CAP) Survey results indicated a lack of comparability of GHB test results among methods and laboratories that represented a major obstacle to meaningful implementation of the ADA guidelines. Thus, an AACC subcommittee was formed in 1993 to develop a standardization program that would enable laboratories to report DCCT-traceable GHB results. This program was implemented in 1996 by the National Glycohemoglobin Standardization Program (NGSP) Steering Committee. APPROACH: We review the NGSP process and summarize progress in standardization through analysis of CAP data. CONTENT: Since 1996, the number of methods and laboratories certified by the NGSP as traceable to the DCCT has steadily increased. CAP GH2-B survey results reported in December 2000 show marked improvement over 1993 data in the comparability of GHB results. In 2000, 90% of surveyed laboratories reported GHB results as hemoglobin A(1c) (HbA(1c)) or equivalent, compared with 50% in 1993. Of laboratories reporting HbA(1c) in 2000, 78% used a NGSP-certified method. For most certified methods in 2000, between-laboratory CVs were <5%. For all certified methods in 2000, the mean percent HbA(1c) was within 0.8% HbA(1c) of the NGSP target at all HbA(1c) concentrations.     

Control of cardiovascular risk factors in patients with diabetes and hypertension at urban academic medical centers

OBJECTIVE: There are national mandates to reduce blood pressure (BP) to <130/85 mmHg, LDL cholesterol to <100 mg/dl, and HbA(1c) to <7% and to institute aspirin therapy in patients with diabetes. The objective of this study was to determine the proportion of patients in urban institutions with diabetes and hypertension who meet these treatment goals. RESEARCH DESIGN AND METHODS: Using American Diabetes Association (ADA) guidelines, we evaluated the control of cardiovascular disease (CVD) risk factors in 1,372 patients receiving medical care at two major urban medical centers in Brooklyn and Detroit. Information was extracted from charts of outpatient clinics. RESULTS: Of 1,372 active clinic patients with diabetes and hypertension, 1,247 (90.9%) had type 2 diabetes, and 26.7% met the target blood pressure of 130/85 mmHg. A total of 35.5% met the goal LDL cholesterol level of <100 mg/dl, 26.7% had an HbA(1c) <7%, and 45.6% were on antiplatelet therapy. Only 3.2% of patients met the combined ADA goal for BP, LDL cholesterol, and HbA(1c). CONCLUSIONS: Optimal control of CVD risk factors in adults with diabetes was achieved only in a minority of patients. Results reflect the inherent difficulties in achieving these complex guidelines in our present health care systems.     

Stressors and self-care challenges faced by adolescents living with type 1 diabetes.

The American Diabetes Association currently recommends that all youth with type 1 diabetes over the age of 7 years follow a plan of intensive management. The purpose of this study was to describe stressors and self-care challenges reported by adolescents with type 1 diabetes who were undergoing initiation of intensive management. Subjects described initiation of intensive management as complicating the dilemmas they faced. The importance of individualized and nonjudgmental care from parents and health care providers was stressed. This study supports development of health care relationships and environments that are teen focused not merely disease-centered and embrace exploring options with the teen that will enhance positive outcomes.     

Clinical and socio-demographic determinants of self-care behaviours in patients with heart failure and diabetes mellitus: A multicentre cross-sectional study

BackgroundSelf-care is vital for patients with heart failure to maintain health and quality of life, and it is even more vital for those who are also affected by diabetes mellitus, since they are at higher risk of worse outcomes. The literature is unclear on the influence of diabetes on heart failure self-care as well as on the influence of socio-demographic and clinical factors on self-care.Objectives(1) To compare self-care maintenance, self-care management and self-care confidence of patients with heart failure and diabetes versus those heart failure patients without diabetes; (2) to estimate if the presence of diabetes influences self-care maintenance, self-care management and self-care confidence of heart failure patients; (3) to identify socio-demographic and clinical determinants of self-care maintenance, self-care management and self-care confidence in patients with heart failure and diabetes.DesignSecondary analysis of data from a multicentre cross-sectional study.SettingOutpatient clinics from 29 Italian provinces.Participants1192 adults with confirmed diagnosis of heart failure.MethodsSocio-demographic and clinical data were abstracted from patients’ medical records. Self-care maintenance, self-care management and self-care confidence were measured with the Self-Care of Heart Failure Index Version 6.2; each scale has a standardized score from 0 to 100, where a score <70 indicates inadequate self-care. Multiple linear regression analyses were performed.ResultsOf 1192 heart failure patients, 379 (31.8%) had diabetes. In these 379, heart failure self-care behaviours were suboptimal (means range from 53.2 to 55.6). No statistically significant differences were found in any of the three self-care measures in heart failure patients with and without diabetes. The presence of diabetes did not influence self-care maintenance (p = 0.12), self-care management (p = 0.21) or self-care confidence (p = 0.51). Age (p = 0.04), number of medications (p = 0.01), presence of a caregiver (p = 0.04), family income (p = 0.009) and self-care confidence (p < 0.001) were determinants of self-care maintenance. Gender (p = 0.01), number of medications (p = 0.004) and self-care confidence (p < 0.001) were significant determinants of self-care management. Number of medications (p = 0.002) and cognitive function (p < 0.001) were determinants of self-care confidence.ConclusionsSelf-care was poor in heart failure patients with diabetes mellitus. This population needs more intensive interventions to improve self-care. Determinants of self-care in heart failure patients with diabetes mellitus should be systematically assessed by clinicians to identify patients at risk of inadequate self-care.