Effect of lifestyle intervention for people with diabetes or prediabetes in real-world primary care: propensity score analysis

Background

It is important to keep the level of antibiotic prescribing low to contain the development of resistant bacteria. This study was conducted to reveal new knowledge about how GPs think in relation to the prescribing of antibiotics - knowledge that could be used in efforts toward rational treatment of infectious diseases in primary care. The aim was to explore and describe the variations in GPs' perceptions of infectious disease management, with special reference to antibiotic prescribing.

Methods

Twenty GPs working at primary care centres in a county in south-west Sweden were purposively selected based on the strategy of including GPs with different kinds of experience. The GPs were interviewed and perceptions among GPs were analysed by a phenomenographic approach.

Results

Five qualitatively different perceptions of infectious disease management were identified. They were: (A) the GP must help the patient to achieve health and well-being; (B) the management must meet the GP's perceived personal, professional and organisational demands; (C) restrictive antibiotic prescribing is time-consuming; (D) restrictive antibiotic prescribing can protect the effectiveness of antibiotics; and (E) patients benefit personally from restrictive antibiotic prescribing.

Conclusions

Restrictive antibiotic prescribing was considered important in two perceptions, was not an issue as such in two others, and was considered in one perception although the actual prescribing was greatly influenced by the interaction between patient and GP. Accordingly, to encourage restrictive antibiotic prescribing several aspects must be addressed. Furthermore, different GPs need various kinds of support. Infectious disease management in primary care is complex and time-consuming, which must be acknowledged in healthcare organisation and planning.     

Investigating concordance in diabetes diagnosis between primary care charts (electronic medical records) and health administrative data: a retrospective cohort study

Background  

Electronic medical records contain valuable clinical information not readily available elsewhere. Accordingly, they hold important potential for contributing to and enhancing chronic disease registries with the goal of improving chronic disease management; however a standard for diagnoses of conditions such as diabetes remains to be developed. The purpose of this study was to establish a validated electronic medical record definition for diabetes.     

Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: an Iranian case study

OBJECTIVES: Information technology is a rapidly expanding branch of science which has affected other sciences. One example of using information technology in medicine is the Electronic Medical Records system. One medical university in Iran decided to introduce such system in its hospital. This study was designed to identify the factors which influence the quality of medical documentation when paper-based records are replaced with electronic records. METHODS: A set of 300 electronic medical records was randomly selected and evaluated against eleven checklists in terms of documentation of medical information, availability, accuracy and ease of use. To get the opinion of the care-providers on the electronic medical records system, ten physicians and ten nurses were interviewed by using of semi-structured guidelines. The results were also compared with a prior study with 300 paper-based medical records. RESULTS: The quality of documentation of the medical records was improved in areas where nurses were involved, but those parts which needed physicians' involvement were actually worse. High workloads, shortage of bedside hardware and lack of software features were prominent influential factors in the quality of documentation. The results also indicate that the retrieval of information from the electronic medical records is easier and faster, especially in emergency situations. CONCLUSIONS: The electronic medical records system can be a good substitute for the paper-based medical records system. However, according to this study, some factors such as low physician acceptance of the electronic medical record system, lack of administrative mechanisms (for instance supervision, neglecting physicians and/or nurses in the development and implementation phases and also continuous training), availability of hardware as well as lack of specific software features can negatively affect transition from a paper-based system to an electronic system.     

Envisioning a learning health care system: the electronic primary care research network, a case study

PURPOSE

The learning health care system refers to the cycle of turning health care data into knowledge, translating that knowledge into practice, and creating new data by means of advanced information technology. The electronic Primary Care Research Network (ePCRN) was a project, funded by the US National Institutes of Health, with the aim to facilitate clinical research using primary care electronic health records (EHRs).

METHODS

We identified the requirements necessary to deliver clinical studies via a distributed electronic network linked to EHRs. After we explored a variety of informatics solutions, we constructed a functional prototype of the software. We then explored the barriers to adoption of the prototype software within US practice-based research networks.

RESULTS

We developed a system to assist in the identification of eligible cohorts from EHR data. To preserve privacy, counts and flagging were performed remotely, and no data were transferred out of the EHR. A lack of batch export facilities from EHR systems and ambiguities in the coding of clinical data, such as blood pressure, have so far prevented a full-scale deployment. We created an international consortium and a model for sharing further ePCRN development across a variety of ongoing projects in the United States and Europe.

CONCLUSIONS

A means of accessing health care data for research is not sufficient in itself to deliver a learning health care system. EHR systems need to use sophisticated tools to capture and preserve rich clinical context in coded data, and business models need to be developed that incentivize all stakeholders from clinicians to vendors to participate in the system.     

Implementation of electronic medical records in hospitals: two case studies

There is evidence that health information technology can improve quality, safety and reduce costs but that health care providers needed more information about how to implement these technologies to realise its potential. This paper summarises the research and proposes a theory of implementation based on the research evidence. The second part describes two implementations of electronic medical record systems and compares the theory against the findings of these two case studies. The paper provides implementers with research-informed guidance about effective implementation, contributes to developing implementation theory and notes policy implications for current national strategies for IT in health.     

Disease-specific medical records improve the recording of processes of care in the management of type 2 diabetes mellitus

A retrospective review of the medical records of 961 patients with type 2 diabetes managed in primary care in Tunisia was undertaken. Recording of process of care measurements improved from 65 to 84% for blood pressure, from 60 to 71% for fasting glucose, and from 11 to 53% for weight measurement (P<0.001 for all). The introduction of disease-specific medical records significantly improves the recording of care of patients with type 2 diabetes mellitus.     

Making the case for a qualitative study of medical errors in primary care

In the interest of publicizing examples of funded qualitative health research, the authors share a proposal to the Agency for Healthcare Research and Quality in Washington, D.C., in which they sought to elicit patient stories of preventable problems in their primary health care that were associated with psychological or physical harms. These stories would allow for the construction of a tentative typology of errors and harms as experienced by patients and the contrasting of this with errors and harms reported by primary care physicians in the United States and other countries. The authors make explicit the anticipated concerns of reviewers more accustomed to quantitative research proposals and the arguments and strategies employed to address them.     

Quality of medical care: a factor analysis approach using medical records.

A relatively inexpensive, reliable, and unobtrusive method is described for measuring the content of medical care. Factor analysis of the content of the records of more than 11,000 physician-patient encounters from six different health insurance plans extracted four main factors or dimensions that together explained 42 percent of the variance in record content. Appropriate names for these dimensions appear to be: "prevention," "rationality," "verification," and "continuity." The method is tested by scoring the six insurance plans on the four factors.     

Process evaluation of a lifestyle intervention to prevent diabetes and cardiovascular diseases in primary care

Effective, cost-effective, safe, and feasible interventions to improve lifestyle behavior in at-risk populations are needed in primary care. In the Hoorn Prevention Study, the authors implemented a theory-based lifestyle intervention in which trained practice nurses used an innovative combination of motivational interviewing (MI) and problem-solving treatment (PST). This article presents the intervention's reach, effectiveness in terms of process outcomes, adoption, and implementation. Recruitment strategy and participant flow were documented accurately. The effectiveness in terms of determinants of behavioral change was measured using a validated questionnaire. Questionnaires were also used to assess participant satisfaction and compliance, as well as practice nurses' confidence in providing the intervention. Counseling sessions were tape recorded to assess MI, PST, and general counseling competence. The findings indicate that the recruitment strategy was adequate and resulted in a reasonably extensive reach of the target population. Practice nurses were competent and confident in their provision of MI and PST, and participant satisfaction was high. Nevertheless, the number of sessions attended was low, and almost no effects were seen on determinants of behavioral change. The authors conclude that implementing this type of intervention in primary care is feasible, but more is needed to effectively facilitate changes in determinants of lifestyle behavior in this population.     

Achieving blood pressure control in patients with diabetes: a case study in primary care

This article presents a case study from a primary care practice that achieves blood pressure control (ie, less than 130/85 mm Hg) in a majority of patients with diabetes. Fifty-three percent of the last blood pressures measured in 2001 were controlled and 38% of patients achieved blood pressure control without medications or with a single agent. Blood pressure control is achieved in a majority of patients in this practice secondary to their focus on guidelines, involvement of nursing staff in case management, and medication use consistent with recommendations.     

妊娠期糖尿病与孕妇饮食及生活方式的病例-对照研究

目的探讨与妊娠期糖尿病(GDM)相关的饮食和生活方式。方法采用1∶2病例-对照研究,选取450例孕妇作为研究对象,包括150例确诊为GDM的孕妇和300例正常孕妇,用问卷调查其一般情况、妊娠情况及饮食生活情况等,并进行t检验和条件Logistic回归分析。结果两组妇女平均每日总能量、蛋白质、脂肪和碳水化合物的摄入量差异均有统计学意义(P≤0.01)。经单因素条件Logistic回归分析共有23个变量与GDM的发生有关,最终进入多因素Logistic回归模型的有7个变量,其中危险因素6个,包括血压高(OR=28.50)、不良孕产史(OR=3.10)、孕前肥胖(OR=2.80)、过量摄入水果(OR=2.40)、糖尿病家族史(OR=1.86)及喜欢吃甜食(OR=1.68);1个保护因素为进食白肉频率较高(OR=0.62)。结论多种饮食生活方式不合理与GDM发病有关;对孕妇应积极开展营养教育,合理选择食物,调整饮食结构,以减少GDM的发病率。     

Measuring the prevalence of diabetes mellitus in a Greek primary health care district

BACKGROUND: Diabetes mellitus is a common disease in developed countries,but in Greece national figures on its prevalence are lacking. OBJECTIVES: The aim of this study was to identify the burden of known diabetesmellitus through its estimation in the area of responsibilityof the Spili Health Centre, based on the health informationsystem that had been established in Primary Health Care in ruralCrete. METHOD: The diagnosis of diabetes was retrospectively documented byreviewing all medical records (n=47151) at the Spili HealthCentre and its five regional outposts during the period 1/6/1988–1/7/1993.The diagnostic criteria of WHO were used to establish the diagnosis. RESULTS: After excluding the patients who had died, we found 210 patientswith diabetes mellitus. Thirty cases were evaluated with OGTTbecause of mild but not diagnostic elevations of fasting plasmaglucose, on more than one occasion. The prevalence of diabetesafter age and sex standardization of that for the European populationwas estimated at 1.52% (1.31% in males and 1.68 in females). CONCLUSIONS: Our study shows that 1) the role of the GPs and one appropriateinformation system in measuring the prevalence of known diabetesmellitus are now considered important within the Greek context;2) diabetes mellitus seems not to be a rare disease in ruralCrete. The estimated prevalence appears to be similar to theprevalence rates reported in other areas of rural Greece. Keywords. Prevalence, diabetes mellitus, Primary Health Care, rural Crete, Greece.     

Annual costs attributed to atrial fibrillation management: cross-sectional study of primary healthcare electronic records

Atrial fibrillation (AF) is the most common chronic arrhythmia, with increasing healthcare and economic burden and a prevalence which increases with progressive ageing. This study aims to describe overall annual costs per patient for management of non-valvular AF in a primary healthcare (PHC) setting and compare these costs between the groups of patients treated with vitamin K antagonists, antiplatelets or non-treated through a population-based study conducted with electronic health records. We analysed annual costs per person of 19,787 patients in 2012; PHC visits, hospital admissions, AF-related events requiring hospital admission, referrals to secondary specialists, sick leave, diagnostic tests and laboratory tests at PHC level, including INR determinations performed in PHC, and drug therapy. Higher costs of AF management were associated with increasing age, male sex, stroke and bleeding risks, comorbidities and occurrence of events associated to AF. The sensitivity analyses conducted showed that PHC visits and hospitalizations represented the most important part of overall costs for all patients.     

Using death certificates and medical examiner records for adolescent occupational fatality surveillance and research: a case study

Death certificates and medical examiner records have been useful yet imperfect data sources for work-related fatality research and surveillance among adult workers. It is unclear whether this holds for work-related fatalities among adolescent workers who suffer unique detection challenges in part because they are not often thought of as workers. This study investigated the utility of using these data sources for surveillance and research pertaining to adolescent work-related fatalities. Using the state of North Carolina as a case study, we analyzed data from the death certificates and medical examiner records of all work-related fatalities data among 11- to 17-year-olds between 1990-2008 (N = 31). We compared data sources on case identification, of completeness, and consistency information. Variables examined included those on the injury (e.g., means), occurrence (e.g., place), demographics, and employment (e.g., occupation). Medical examiner records (90%) were more likely than death certificates (71%) to identify adolescent work-related fatalities. Data completeness was generally high yet varied between sources. The most marked difference being that in medical examiner records, type of business/industry and occupation were complete in 72 and 67% of cases, respectively, while on the death certificates these fields were complete in 90 and 97% of cases, respectively. Taking the two sources together, each field was complete in upward of 94% of cases. Although completeness was high, data were not always of good quality and sometimes conflicted across sources. In many cases, the decedent's occupation was misclassified as "student" and their employer as "school" on the death certificate. Even though each source has its weaknesses, medical examiner records and death certificates, especially when used together, can be useful for conducting surveillance and research on adolescent work-related fatalities. However, extra care is needed by data recorders to ensure that occupation and employer are properly coded when dealing with adolescent worker deaths.     

Acceptability to primary care providers of telemedicine in diabetes case management

We studied the perceptions of primary care providers (PCPs) about the telemedicine intervention in a trial of telemedicine for management of diabetes in medically under-served areas of New York State. A survey was mailed to 206 rural and 159 urban PCPs. The response rates were 25% and 22%, respectively. Eighty percent of respondents believed that a diabetes telemedicine case management system would help their practice. An overall satisfaction score (possible range 0-80) suggested good acceptability (mean 66, SD 12). In multiple linear regression, the rural location and younger age of the PCPs were independent predictors of higher satisfaction (both P < 0.01). Within-PCP comparisons showed a higher perceived impact on patients, as compared to impact on PCP practices (P < 0.001). However, the findings should be interpreted with caution due to the low response rates.