Shaping the course of a marathon: using the Trajectory Framework for diabetes mellitus.

Persons with either insulin-dependent or non-insulin-dependent diabetes mellitus live with a chronic illness that can have both acute and long-term complications. The therapeutic regimen for glycemic control in diabetes is often complex and is lifelong; it requires special knowledge and skills for both patients and health care providers. In this article, the Corbin and Strauss trajectory framework for chronic illness management is clinically applied to the planning of patient care in two case studies of persons with diabetes. The benefits of using the trajectory framework as a model for care in diabetes include: introduction of the concepts of "locating" the patient on the trajectory and assessing the trajectory projection for both patient and provider, and a more realistic evaluation of incremental change in chronic illness. Two possible barriers to clinical application of the framework for diabetes management are: difficulty in translating the framework for clinical use, and some terminology in the framework that does not seem to describe reimbursable care. The trajectory framework provides a necessary shift in focus to quality of life issues in diabetes management over the lifespan.     

Web-Based Collaborative Care for Type 2 Diabetes: A pilot randomized trial

OBJECTIVE—To test Web-based care management of glycemic control using a shared electronic medical record with patients who have type 2 diabetes.RESEARCH DESIGN AND METHODS—We conducted a trial of 83 adults with type 2 diabetes randomized to receive usual care plus Web-based care management or usual care alone between August 2002 and May 2004. All patients had GHb ≥7.0%, had Web access from home, and could use a computer with English language–based programs. Intervention patients received 12 months of Web-based care management. The Web-based program included patient access to electronic medical records, secure e-mail with providers, feedback on blood glucose readings, an educational Web site, and an interactive online diary for entering information about exercise, diet, and medication. The primary outcome was change in GHb.RESULTS—GHb levels declined by 0.7% (95% CI 0.2−1.3) on average among intervention patients compared with usual-care patients. Systolic blood pressure, diastolic blood pressure, total cholesterol levels, and use of in-person health care services did not differ between the two groups.CONCLUSIONS—Care management delivered through secure patient Web communications improved glycemic control in type 2 diabetes.Health care limited to clinic visits does not meet the needs of many patients with diabetes. Care systems that use Web-based communication provide an opportunity to shift the focus in health care away from the office and toward patients’ daily lives at home. Patient interaction with online care plans and electronic medical records may further enhance the effectiveness of chronic care (1,2). Little is known, however, about the impact of using Web communications and shared electronic medical records in the primary care of patients with diabetes.We present the results of a randomized trial examining a Web-based diabetes support program that aimed to improve glycemic control for patients with type 2 diabetes. The program consisted of access from home to the electronic medical record, secure electronic communications between patients and providers, and interactive disease management tools. We hypothesized that glycemic control would improve in the group receiving the intervention.     

Spurious elevation of hemoglobin A1c by hereditary persistence of fetal hemoglobin

We present the case of a 61- year-old black woman with a diagnosis of type 2 diabetes and a falsely elevated hemoglobin A1c (HbA1c) due to hereditary persistence of fetal hemoglobin. Physicians and allied health care professionals are alerted to this potentially significant problem in the diagnosis and management of diabetes mellitus (DM), particularly in the wake of the Diabetes Complications and Control Trial when "strict" glycemic control assessed by HbA1c is now the standard of care.     

Hyperglycemic Crisis

Background

Hyperglycemic crisis is a metabolic emergency associated with uncontrolled diabetes mellitus that may result in significant morbidity or death. Acute interventions are required to manage hypovolemia, acidemia, hyperglycemia, electrolyte abnormalities, and precipitating causes. Despite advances in the prevention and management of diabetes, its prevalence and associated health care costs continue to increase worldwide. Hyperglycemic crisis typically requires critical care management and hospitalization and contributes to global health expenditures.

Objective

Diagnostic and resolution criteria and management strategies for diabetic ketoacidosis and hyperosmolar hyperglycemic crisis are provided. A discussion of prevalence, mortality, pathophysiology, risk factors, clinical presentation, differential diagnosis, evaluation, and management considerations for hyperglycemic crisis are included.

Discussion

Emergency physicians confront the most severe sequelae of uncontrolled diabetes and provide crucial, life-saving management. With ongoing efforts from diabetes societies to incorporate the latest clinical research to refine treatment guidelines, management and outcomes of hyperglycemic crisis in the emergency department continue to improve.

Conclusion

We provide an overview of the evaluation and treatment of hyperglycemic crisis and offer a concise, targeted management algorithm to aid the practicing emergency physician.     

Does Diabetes Care Differ by Type of Chronic Comorbidity?: An evaluation of the Piette and Kerr framework

OBJECTIVE

To evaluate the relationship between diabetes care and types of comorbidity, classified by the degree to which their treatment is concordant with that for diabetes.

RESEARCH DESIGN AND METHODS

Retrospective cohort study (fiscal year [FY] 2001 to FY 2004) of 42,826 veterans with new-onset diabetes in FY 2003. Veterans were classified into five chronic comorbid illness groups (CCIGs): none, concordant only, discordant only, both concordant and discordant, and dominant. Five diabetes-related care measures were assessed in FY 2004 (guideline-consistent testing and treatment goals for HbA_1c and LDL cholesterol and diabetes-related outpatient visits). Analyses included logistic regressions adjusting for age, race, sex, marital status, priority code, and interaction between CCIGs and visit frequency.

RESULTS

Only 20% of patients had no comorbidities. Mean number of visits per year ranged from 7.8 (no CCIG) to 17.5 (dominant CCIG). In unadjusted analyses, presence of any illness was associated with equivalent or better care. In the fully adjusted model, we found interaction between CCIG and visit frequency. When visits were <7 per year, the odds of meeting the goal of HbA_1c <8% were similar in the concordant (odds ratio 0.96 [95% CI 0.83–1.11]) and lower in the discordant (0.90 [0.81–0.99]) groups compared with the no comorbidity group. Among patients with >24 visits per year, these odds were insignificant. Dominant CCIG was associated with substantially reduced care for glycemic control for all visit categories and for lipid management at all but the highest visit category.

CONCLUSIONS

Our study indicates that diabetes care varies by types of comorbidity. Concordant illnesses result in similar or better care, regardless of visit frequency. Discordant illnesses are associated with diminished care: an effect that decreases as visit frequency increases.Comorbid illnesses among patients may complicate care by competing for time, attention, or other resources (1–5). This is particularly applicable for patients with chronic illnesses, such as diabetes. As a consequence, the quality of diabetes care might be compromised unless additional resources are made available to compensate.Comorbid illnesses are common among patients with diabetes. In 2004, 88.6% of people with diabetes who responded to the Medical Expenditure Panel Survey reported having at least one additional chronic illness, while close to 15% reported having four or more, illustrating how common comorbidity is among the diabetic population (2). The prevalence of both diabetes and comorbid illness is likely to increase as the U.S. population ages.Despite a high level of comorbidity among diabetic patients, the literature studying the effect of comorbidity on diabetes care predominantly focuses on a single coexisting condition, such as a mental illness (6–9). On the other hand, researchers accounting for all concurrent morbidity have applied aggregate morbidity counts or one-dimensional scores (10,11). Both approaches fail to reveal the true impact of multiple comorbid illnesses because not all illnesses are likely to have the same impact. Measuring patient complexity still poses a challenge to both clinicians and researchers, as described in a recent article (12).Piette and Kerr (13) have proposed a novel theoretical framework as a way to categorize the effect of comorbidity on patients with diabetes and other chronic illnesses. The Piette and Kerr framework groups comorbid illnesses as concordant illnesses (illnesses that overlap with diabetes in their pathogenesis and management plans [e.g., cardiovascular diseases]), discordant illnesses (illnesses with unrelated pathogenesis or management plans [e.g., mental health illnesses and musculoskeletal disorders]), and dominant illnesses (illnesses whose severity eclipses all other illness management plans [e.g., end-stage kidney and liver diseases and metastatic cancer]). The framework hypothesizes that effects differ depending on the nature of comorbid illness (13–15). The presence of a discordant illness may draw resources away from diabetes management and result in compromised diabetes care, the presence of a concordant illness may result in similar or better diabetes care, and the presence of a dominant illness may result in substantially worse diabetes care. The primary purpose of this study was to evaluate the relationship between diabetes care and different types of comorbid illnesses, classified by the degree to which their treatment is concordant with that for diabetes as described by Piette and Kerr (13). We hypothesized that having concordant illnesses would be associated with similar or better diabetes care outcomes, having discordant illnesses would be associated with worse diabetes care outcomes, and the presence of dominant illnesses would lead to substantially worse diabetes care outcomes.     

Organizational factors affecting the adoption of diabetes care management processes in physician organizations

OBJECTIVE: To describe the extent of adoption of diabetes care management processes in physician organizations in the U.S. and to investigate the organizational factors that affect the adoption of diabetes care management processes. RESEARCH DESIGN AND METHODS: Data are derived from the National Survey of Physician Organizations and the Management of Chronic Illness, conducted in 2000-2001. A total of 1,104 of the 1,590 physician organizations identified responded to the survey. The extent of adoption of four diabetes care management processes is measured by an index consisting of the organization's use of diabetic patient registries, clinical practice guidelines, case management, and physician feedback. The ordinary least-squares model is used to determine the association of organizational characteristics with the adoption of diabetes care management processes in physician organizations. A logistic regression model is used to determine the association of organizational characteristics with the adoption of individual diabetes care management processes. RESULTS: Of the 987 physician organizations studied that treat patients with diabetes, 48% either do not use any or use only one of the four diabetes care management processes. A total of 20% use two care management processes, and 32% use three or four processes. External incentives to improve quality, computerized clinical information systems, and ownership by hospitals or health maintenance organizations are strongly associated with the diabetes care management index and the adoption of individual diabetes care management processes. CONCLUSIONS: Policies to encourage external incentives to improve quality and to facilitate the adoption of computerized clinical information technology may promote greater use of diabetes care management processes.     

Hypertension in people with type 2 diabetes: Update on pharmacologic management

Objective

To summarize the evidence for the need to improve pharmacologic management of hypertension in people with type 2 diabetes and to provide expert advice on how blood pressure (BP) treatment can be improved in primary care.

Sources of information

Studies were obtained by performing a systematic review of the literature on hypertension and diabetes, from which management recommendations were developed, reviewed, and voted on by a group of experts selected by the Canadian Hypertension Education Program and the Canadian Diabetes Association; authors’ expert opinions on optimal pharmacologic management were also considered during this process.

Main message

The pathogenesis of hypertension in patients with diabetes is complex, involving a range of biological and environmental factors and genetic predisposition; as a result, hypertension in people with diabetes incurs higher associated risks and adverse events. Mortality and morbidity are heightened in diabetes patients who do not achieve BP control (ie, a target value of less than 130/80 mm Hg). Large randomized controlled trials and meta-analyses of randomized controlled trials have shown that reducing BP pharmacologically is single-handedly the most effective way to reduce rates of death and disability in patients with diabetes, particularly associated cardiovascular risks. Often, combinations of 2 or more drugs (diuretics, angiotensin-converting enzyme inhibitors, β-blockers, angiotensin receptor blockers, calcium channel blockers, spironolactone, etc) are required for pharmacotherapy to be effective, particularly for patients in whom BP is difficult to control. However, the health care costs associated with extensively lowering BP are substantially less than the costs associated with treating the complications that can be prevented by lowering BP.

Conclusion

Detecting and managing hypertension in people with diabetes is one of the most effective measures to prevent adverse events, and pharmacotherapy is one of the most effective ways to maintain target BP levels in primary care.     

Diabetes Preventive Services and Policy Implications in the U.S.

OBJECTIVE

To investigate whether the patient or physician practice characteristics predict the use of diabetes preventive care services.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of a nationally representative sample of 27,169 adult ambulatory care visits, using the 2007 National Ambulatory Medical Care Survey data. The outcome variable is whether any preventive care services, defined as diagnostic tests (glucose, urinalysis, A1C, and blood pressure) or patient education (diet/nutrition, exercise, and stress management), were ordered/provided. Multivariate analysis was performed to identify independent predictors of diabetes preventive care services, controlling for patient and physician practice characteristics. All analyses were adjusted for the complex survey design and analytic weights.

RESULTS

Compared with people without diabetes, diabetic patients were older (63 vs. 53 years; P < 0.01) and were more likely to be nonwhite and covered by Medicare insurance. In multivariate analyses, younger patients and the availability of primary care physicians, electronic medical records, and on-site laboratory tests were associated with more effective preventive care services (P < 0.05). If physician compensation relied on productivity, preventive care services were less likely (odds ratio 0.4 [95% CI 0.27–0.82 for men and 0.26–0.81 for women]). Although the patterns of patient education and diagnostic testing were similar, the provision of patient education was less likely than that of diagnostic testing.

CONCLUSIONS

Primary care physicians and practice features seem to steer diabetes preventive services. Given the time constraints of physicians, strategies to strengthen structural capabilities of primary care practices and enhance partnerships with public health systems on diabetic patient education are recommended.Diabetes is a common chronic condition and costly disease that demands effective preventive care services (1). In 2007, an estimated 23.6 million people in the U.S. had diabetes (2). Patients with diabetes have an increased risk of morbidity and mortality from several conditions, such as cardiovascular, cerebrovascular, or kidney diseases and heart failure (3–5). Previous studies have shown that interventions or intensive management of glucose and hypertension are likely to reduce the morbidity and mortality of diabetes-related complications (6,7). In addition, economic analysis indicates that mean total costs associated with microvascular complications have almost doubled compared with those for patients without these complications (1). Thus, both intervention and economic studies suggest the critical importance of providing effective interventions and preventive care services for patients with diabetes. However, underuse of recommended preventive services is reported for people with diabetes (5). Furthermore, it is unclear whether patient or physician practice characteristics predict the use of diabetes preventive services. Given the racial/ethnic differences in mean glucose, diabetes prevalence, and diabetes-related cardiovascular disease (8,9), it is important to identify whether there are disparities in the provision of preventive care services for patients with diabetes.To our knowledge, no previous study has examined the utilization patterns of preventive care services for patients with diabetes in a national sample of adult ambulatory care visits. Therefore, the newly released data from the 2007 National Ambulatory Medical Care Survey (NAMCS) were selected to investigate the use of diabetes preventive services during routine care for preventing the long-term complications of diabetes. The objective of this analysis was to identify whether patient or physician practice characteristics predict the likelihood of diabetes preventive care services.     

Beliefs about health and diabetes in men of different ethnic origin

AIM: This paper reports the findings of a study exploring the health and illness beliefs of men with diabetes, who were from different cultural backgrounds and living in Sweden. BACKGROUND: No studies have been reported that have focused on the beliefs about health and illness in men with diabetes mellitus of different ethnic origin. Beliefs may affect self-care and care-seeking behaviour. METHOD: An explorative study design and purposive sampling procedure was used. Focus-group interviews were held with 35 men with diabetes and aged between 39 and 78 years. Fourteen participants were born in Arabic countries, 10 in former Yugoslavia and 11 in Sweden. FINDINGS: Important factors for health were the ability to be occupied/employed and economically independent and, especially among Arabs and former Yugoslavians, sexual functioning. Swedes focused on heredity, lifestyle and management of diabetes, while non-Swedes claimed the influence of supernatural factors and emotional stress related to the role of being an immigrant and migratory experiences as factors related to development of diabetes and having a negative influence on health. Swedes and Arabs described health as "freedom from disease" in contrast to many former Yugoslavians who described health as "wealth and the most important thing in life". Knowledge about diabetes was limited among the men studied, but Arabs showed an active information-seeking behaviour compared with Swedes and former Yugoslavians. Non-Swedish respondents, particularly Arabs, had sought help from health care professionals to a greater extent than Swedes, who were more likely to use self-care measures. CONCLUSION: Being occupied/employed and having knowledge about the body and management of diabetes are important for positive health development. There are dissimilarities in beliefs about health and diabetes that influence self-care behaviour and health care seeking. Men's cultural backgrounds and spiritual beliefs need to be considered in diabetes care.     

Regional Primary Care Team to Deliver Best-Practice Diabetes Care: A needs-driven health workforce model reflecting a biopsychosocial construct of health

OBJECTIVE

Best-practice diabetes care can reduce the burden of diabetes and associated health care costs. But this requires access to a multidisciplinary team with the right skill mix. We applied a needs-driven evidence-based health workforce model to describe the primary care team required to support best-practice diabetes care, paying particular attention to diverse clinic populations.

RESEARCH DESIGN AND METHODS

Care protocols, by number and duration of consultations, were derived for twenty distinct competencies based on clinical practice guidelines and structured input from a multidisciplinary clinical panel. This was combined with a previously estimated population profile of persons across 26 patient attributes (i.e., type of diabetes, complications, and threats to self-care) to estimate clinician contact hours by competency required to deliver best-practice care in the study region.

RESULTS

A primary care team of 22.1 full-time-equivalent (FTE) positions was needed to deliver best-practice primary care to a catchment of 1,000 persons with diabetes with the attributes of the Australian population. Competencies requiring greatest contact time were psychosocial issues and dietary advice at 3.5 and 3.3 FTE, respectively (1 FTE/∼300 persons); home (district) nursing at 3.2 FTE; and diabetes education at 2.8 FTE. The annual cost of delivering care was estimated at just over 2,000 Australian dollars (∼2,090 USD) (2012) per person with diabetes.

CONCLUSIONS

A needs-driven approach to primary care service planning identified a wider range of competencies in the diabetes primary and community care team than typically described. Access to psychosocial competences as well as medical management is required if clinical targets are to be met, especially in disadvantaged groups.Diabetes is a significant global health issue. In Australia, ~4% of the population (818,200 persons) were diagnosed with diabetes in 2008 (1), with a further 3.6% estimated undiagnosed cases. Globally, the prevalence of diabetes is estimated at 150 million (2), which is expected to climb to >366 million by 2030 (2).Diabetes is associated with high rates of complications that affect all organ systems and include cardiovascular disease, kidney disease, diabetic retinopathy, neuropathy, and sexual dysfunction (3). Diabetes is associated with substantial disease burden, accounting in Australia for 5.5% of all disability-adjusted life years lost due to disease and injury (4). Advanced disease adds to health system costs (5,6).Diabetes is classified as ambulatory care sensitive, reflecting strong evidence that best-practice primary and community care can avert hospitalizations (7). There is also evidence that multidisciplinary team care consistent with best-practice guidelines is both effective and cost-effective relative to societal standards for funding of health services (8,9).Delivery of best-practice, guideline-informed care can markedly improve clinical outcomes in patients with chronic disease (10). However, it is also noted that clinical practice guidelines do not cover all major influences on care outcomes, such as psychosocial issues, patient preferences, and other influences on self-care capacity (11). Effective diabetes care depends in part on self-care capacity, which is influenced by factors such as health literacy, physical limitations, comorbid illness, cognitive ability, nonnative language proficiency, mental well-being, and exposure to social insults (12). Patients characterized by these threats to self-care are linked to poorer adherence to recommended diabetes treatment (13–18), worse glycemic control (16,17,19), and increased rates of complications (15). In addition, these patient attributes have been associated with poorer quality care (15).An approach to patient management that is cognizant of patient characteristics that can threaten self-care capacity (attributes most common in disadvantaged groups) may attenuate the poor health outcomes observed in disadvantaged groups. Ideally, the primary care team should incorporate the mix of skills needed to address the diverse attributes of the clinic population. This should reflect not only the clinical diagnoses but also attributes that threaten self-care capacity. Study findings that the provision of an appropriately skilled, multidisciplinary team can deliver better outcomes at lower costs of care compared with usual care provided by a medical team (20,21) support this approach.The aim of the research reported here was to define the competencies and skill mix required to deliver best-practice diabetes care in the primary and community care setting, taking into account a wide range of patient characteristics that can affect care outcomes. The results of this research could then be used by service planners to identify the desirable composition of the diabetes primary care team and the regional health workforce to support optimal diabetes management.     

Barriers and Potential Solutions to Providing Optimal Guideline-Driven Care to Patients With Diabetes in the U.S.

The cost of diabetes, driven primarily by the cost of preventable diabetes complications, will continue to increase with the epidemic rise in its prevalence in the U.S. The Diabetes Working Group (DWG), a consortium of professional organizations and individuals, was created to examine the barriers to better diabetes care and to recommend mitigating solutions. We consolidated three sets of guidelines promulgated by national professional organizations into 29 standards of optimal care and empanelled independent groups of diabetes care professionals to estimate the minimum and maximum time needed to achieve those standards of care for each of six clinical vignettes representing typical patients seen by diabetes care providers. We used a standards-of-care economic model to compare provider costs with reimbursement and calculated “reimbursement gaps.” The reimbursement gap was calculated using the maximum and minimum provider cost estimate (reflecting the baseline- and best-case provider time estimates from the panels). The cost of guideline-driven care greatly exceeded reimbursement in almost all vignettes, resulting in estimated provider “losses” of 470,000–750,000 USD/year depending on the case mix. Such “losses” dissuade providers of diabetes care from using best practices as recommended by national diabetes organizations. The DWG recommendations include enhancements in care management, workforce supply, and payment reform.The prevalence of diabetes in the U.S. has more than tripled from 5.6 to 19.7 million people between 1980 and 2009 and is anticipated to reach ~42 million people by 2034 (1,2). This high and growing prevalence of diabetes translates into high current (245 billion USD as of 2010) and projected (334 USD billion by 2034) costs, most of which are for treatment of diabetes complications (3,4). Previous large randomized controlled trials have demonstrated that the rate at which diabetes complications develop can be reduced in cost-effective ways, but translating these findings into clinical practice has been only modestly successful because of the existence of several barriers to providing guideline-directed care (5–10). The medical community must find methods to overcome these barriers in the hope that it will reverse these ominous trends. Many interconnected obstacles to achieving optimal diabetes care exist, including patient barriers (behavioral, psychosocial, and socioeconomic), structural and technological hurdles, and provider and delivery system concerns. DWG, primarily a consortium of professional societies, was formed in 2009 to study crucial aspects of this problem and recommend solutions.     

Management of glycemia in type 2 diabetes

The management of type 2 diabetes has been revolutionized over the last 3 to 5 years as a result of dramatic changes in our health care system, new clinical trial data, novel pharmacologic agents, and a better understanding of appropriate methods for patient education regarding lifestyle issues. As a result, diabetes management has become much more heterogeneous, with dramatic differences in style and approach used by practitioners, whether diabetes specialists, primary care providers, or allied health professionals. Diabetes care has also become much more rewarding: The vast majority of patients can now achieve excellent glycemic control while leading full and unrestricted lives. In this article, a construct is reviewed by which comprehensive diabetes care may be approached in a primary care setting. The overall goal of diabetes management should be to provide an opportunity for patients to live out their normal life expectancies with minimal complications. In other articles, screening and treatment suggestions for diabetes complications are provided. Prospective interventional and epidemiologic studies demonstrate that glycemic control is critical to avoidance of complications; the methods to achieve glycemic control are the major focus of this chapter.     

Quality of chronic kidney disease management in primary care: a retrospective study

Background: Early detection and appropriate management of chronic kidney disease (CKD) in primary care are essential to reduce morbidity and mortality. Aim: To assess the quality of care (QoC) of CKD in primary healthcare in relation to patient and practice characteristics in order to tailor improvement strategies. Design and setting: Retrospective study using data between 2008 and 2011 from 47 general practices (207 469 patients of whom 162 562 were adults). Method: CKD management of patients under the care of their general practitioner (GP) was qualified using indicators derived from the Dutch interdisciplinary CKD guideline for primary care and nephrology and included (1) monitoring of renal function, albuminuria, blood pressure, and glucose, (2) monitoring of metabolic parameters, and alongside the guideline: (3) recognition of CKD. The outcome indicator was (4) achieving blood pressure targets. Multilevel logistic regression analysis was applied to identify associated patient and practice characteristics. Results: Kidney function or albuminuria data were available for 59 728 adult patients; 9288 patients had CKD, of whom 8794 were under GP care. Monitoring of disease progression was complete in 42% of CKD patients, monitoring of metabolic parameters in 2%, and blood pressure target was reached in 43.1%. GPs documented CKD in 31.4% of CKD patients. High QoC was strongly associated with diabetes, and to a lesser extent with hypertension and male sex. Conclusion: Room for improvement was found in all aspects of CKD management. As QoC was higher in patients who received structured diabetes care, future CKD care may profit from more structured primary care management, e.g. according to the chronic care model.

• Key points

• Quality of care for chronic kidney disease patients in primary care can be improved.

• In comparison with guideline advice, adequate monitoring of disease progression was observed in 42%, of metabolic parameters in 2%, correct recognition of impaired renal function in 31%, and reaching blood pressure targets in 43% of chronic kidney disease patients.

• Quality of care was higher in patients with diabetes.

• Chronic kidney disease management may be improved by developing strategies similar to diabetes care.

     

Formal clinical primary health care training. Does it make a difference?

Throughout South Africa, primary clinical care is mainly provided by nurses. In line with this, most professional nurses of the former Bloemfontein local authority completed a one year "Advanced Diploma in Health Assessment, Diagnosis and Treatment" course at the University of the Free State. This study aimed to compare the clinical competencies of nurses who obtained this diploma with those who did not. The primary objective was to assess the clinical management of one chronic and one acute disease (diabetes mellitus and acute respiratory tract infections in adults, respectively) for these two groups of nurses. Relationships between quality of care and nurses' and clinics' characteristics were also examined since they could be predictors of quality of care, independent of the influence of training. We reviewed records of 286 consecutive visits for adults with diabetes and 293 consecutive visits for adults with an acute respiratory tract infection (ARTI). Nurses completed questionnaires on nurse characteristics, while the researchers obtained the information about the clinics. Recording of important generic (for ARTIs) and disease-specific steps (for diabetes) in patient management were assessed. Results for patients of "trained" and "non-trained" professionals were compared and adjusted for nurses', clinics' and patients' characteristics. There was generally little evidence of patients being thoroughly managed. Formal training was marginally associated with better care for ARTIs (p = 0.06) but not for diabetes (p = 0.47). Other factors associated with more thorough care were years of experience in curative primary health care (p = 0.006) and additional nursing degrees for ARTIs (p = 0.03) and the presence of enrolled or assistant nurses at the clinic for diabetes (p = 0.06). Fixed clinics generally performed better than mobile and satellite clinics.     

Inpatient Management of Diabetic Foot Disorders: A Clinical Guide

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders and to optimize the transition from inpatient to outpatient care. Pathways for the outpatient management of diabetic foot disorders are available; however, little has been written on the inpatient management of these disorders while patients are hospitalized. A multidisciplinary group was assembled on the basis of their experience in treating patients with diabetic foot disorders and tasked with preparing a guideline to assist practitioners who care for hospitalized patients. Medical specialists (infectious disease, hospital medicine, and endocrinology), surgical specialists (podiatry, plastic surgery, and orthopedic surgery), diabetes educators, and nursing staff contributed to this article. Members were assigned to research and write on their areas of expertise using an evidence-based approach and incorporating their own expert opinions when a lack of evidence existed.The lower extremity manifestations of diabetes are multifactorial, and the approach to treatment and prevention of complications should take each of the key factors into consideration. Physicians, surgeons, nurses and other staff play a central role in the management and screening of the inpatient with diabetes (1). Although the staffing of this team might vary from region to region, or even over time, the skill sets required remain constant. For patients with diabetes whose primary admission is not for a lower extremity wound, provisions should be made during the hospitalization to screen for diabetic foot complications and implement preventative care practices. Nondiabetic patients presenting with foot lesions, particularly if neuropathic and/or ischemic, should be screened for diabetes: foot ulcers and infection may be the presenting sign of diabetes.     

The relationship between financial incentives and quality of diabetes care in Ontario, Canada

OBJECTIVE

We assessed the impact of a diabetes incentive code introduced for primary care physicians in Ontario, Canada, in 2002 on quality of diabetes care at the population and patient level.

RESEARCH DESIGN AND METHODS

We analyzed administrative data for 757,928 Ontarians with diabetes to examine the use of the code and receipt of three evidence-based monitoring tests from 2006 to 2008. We assessed testing rates over time and before and after billing of the incentive code.

RESULTS

One-quarter of Ontarians with diabetes had an incentive code billed by their physician. The proportion receiving the optimal number of all three monitoring tests (HbA_1c, cholesterol, and eye tests) rose gradually from 16% in 2000 to 27% in 2008. Individuals who were younger, lived in rural areas, were not enrolled in a primary care model, or had a mental illness were less likely to receive all three recommended tests. Patients with higher numbers of incentive code billings in 2006–2008 were more likely to receive recommended testing but also were more likely to have received the highest level of recommended testing prior to introduction of the incentive code. Following the same patients over time, improvement in recommended testing was no greater after billing of the first incentive code than before.

CONCLUSIONS

The diabetes incentive code led to minimal improvement in quality of diabetes care at the population and patient level. Our findings suggest that physicians who provide the highest quality care prior to incentives may be those most likely to claim incentive payments.Diabetes accounts for an increasing proportion of the global burden of disease and currently is the fifth or sixth most common cause of death in most developed countries (1). It is well established that appropriate monitoring and treatment can significantly reduce the incidence of diabetes complications and improve overall morbidity and mortality (2–6). However, numerous studies, both globally and in Canada, have shown that the quality of diabetes care, measured by adherence to recommended processes or attainment of treatment goals, consistently falls short of evidence-based guidelines (7).Over the last decade, many countries have implemented pay-for-performance programs in an effort to improve the quality of health care, but there still is limited evidence to support the effectiveness of this approach (8,9). In 2002, the government in Ontario, Canada, introduced a new fee code for primary care physicians to encourage regular, comprehensive management of diabetic patients (10). When introduced, this code could be billed a maximum of three times a year per patient at a value of $37.00 (Canadian) per visit and required maintenance of a diabetes flow sheet that tracked cholesterol, hemoglobin A_1c (HbA_1c), retinal eye examination, blood pressure, weight, and other parameters relevant to diabetes management (11). It is unclear, however, whether the new incentive code has had any impact on the quality of care provided.In this study, we aimed to investigate the quality of diabetes care, measured by receipt of three evidence-based monitoring tests, and to assess the impact of the new diabetes incentive code in Ontario on quality of care at the population and patient level. We also sought to identify patient and physician characteristics associated with higher quality care.