Exploring Disease Management Programs for Diabetes Mellitus

Diabetes mellitus is a chronic illness that affects the world on an epidemic scale. It requires complex healthcare and considerable economic resources. Diabetes disease management programs use a variety of strategies to improve clinical outcome measures and reduce costs. Studies have demonstrated the effectiveness of these programs on reducing glycosylated hemoglobin levels, improving cardiovascular risks, and reducing utilization of services. However, the most effective components of disease management strategies or combination of strategies remain unknown. This narrative review explores the components, impact, benefits, and barriers of current diabetes disease management models and also presents a novel hybrid model incorporating elements of both on-site and off-site programs.On-site disease management programs include strategies characterized by unique patient identification and evaluation, implementation of intervention methods, on-site health provider team members, and specific environmental resources. Advantages of this model include the face-to-face encounter between patients and providers, the proximity of the healthcare team members to facilitate ease of communication and build independence and trust between patients and providers, and technology resources, such as the electronic medical record. A number of clinical trials have demonstrated the effectiveness and cost effectiveness of on-site diabetes disease management programs. However, because of the methodological limitations of many studies, further studies are needed to confirm such findings. Barriers to the implementation of on-site programs may include patient population characteristics such as complexity of co-morbid illness and social Stressors, including low health literacy, that require adaptation of the disease management model. In comparison, off-site disease management programs utilize administrative resources to identify patients with chronic illnesses. Other key elements include the evaluation of clinical care practices using established guidelines with auditing and feedback to providers based on their performance, and the use of reminders for both patients and providers to influence better processes of care. This process is often independent of the traditional on-site care delivered directly by providers.A hybrid disease management model that incorporates both on-site and off-site disease management components could be the ideal model for optimizing care of patients with chronic illness. The suggested hybrid model incorporates many features of previous models of disease management but gives a new construct that can be customized to different clinic settings, provider practices, and patient populations, including patients with other complex chronic illness. This hybrid model could be applied to a variety of individual or multiple chronic illnesses. This model would engage both on-site healthcare providers and support staff along with off-site administrative staff and electronic medical data to provide patients optimal care while potentially reducing overall costs.     

‘Managing patient involvement’: provider perspectives on diabetes decision‐making

Background Most studies of shared decision‐making focus on acute treatment or screening decision‐making encounters, yet a significant proportion of primary care is concerned with managing patients with chronic disease. Aim To investigate provider perspectives on the role of patient involvement in chronic disease decision‐making. Design A qualitative, grounded theory study of patient involvement in diabetes care planning. Setting and participants Interviews were conducted with 29 providers (19 general practitioners, eight allied health providers, and two endocrinologists) who participated in diabetes care planning. Results Providers described a conflict between their responsibilities to deliver evidence‐based diabetes care and to respect patients’ rights to make decisions. While all were concerned with providing best possible diabetes care, they differed in the emphasis they placed on ‘treating to target’ or practicing ‘personalized care’. Those preferring to ‘treat to target’ were more assertive, while ‘personalized care’ meant being more accepting of the patient’s priorities. Providers sought to manage patient involvement in decision‐making according to their objectives. ‘Treating to target’ meant involving patients where necessary to tailor care to their needs and abilities, but limiting patient involvement in decisions about the overall agenda. ‘Personalized care’ meant involving patients to tailor care to patient preference. Discussion and conclusions Respecting a patient’s autonomy and delivering high‐quality diabetes care are important to providers. At times it may not be possible to do both, so a careful balance is required. Involving patients in decision‐making may be a means to this end, rather than an end in itself.     

Diabetes stories: use of patient narratives of diabetes to teach patient-centered care

A critical component to instituting compassionate, patient-centered diabetes care is the training of health care providers. Our institution developed the Family Centered Experience (FCE), a comprehensive 2-year preclinical program based on longitudinal conversations with patients about living with chronic illness. The goal of the FCE is to explore the experience of illness from the patient’s perspective and ultimately to incorporate this perspective in clinical practice. In this qualitative study, we wished to investigate the impact of “diabetes stories”—the stories of FCE volunteers with diabetes—on medical students’ understanding of diabetes and its management. Individual interviews were conducted with medical students who had worked with a volunteer with diabetes to answer the questions: “in what ways was learning through these ‘diabetes stories’ different from that acquired through lectures and textbooks,” and “how did these stories impact the students’ understanding of diabetes and its care?” Thematic analysis of the transcribed interviews was performed using Grounded Theory. Several major themes emerged: There was more to diabetes than the “scientific” knowledge acquired through lectures; the stories challenged students’ assumptions about having or working with people with diabetes and allowed students to see the world through the perspective of someone with diabetes, and the stories motivated students’ development as physicians and influenced their general perspectives of doctoring and medicine. First-person narratives of living with diabetes allow for learning in affective, experiential, and cognitive dimensions, stimulate self reflection and perspective-taking, and enhance growth through the challenging of previous assumptions, beliefs, and perspectives. This type of learning is transformative and may result in a shift in students’ perspectives towards more open, inclusive attitudes towards patient-centered diabetes care.     

Gaps in transitional care: what are the perceptions of adolescents,parents and providers?

Background Several studies have investigated preferences and experiences of adolescents with different chronic conditions and their parents. Some have included the provider's perspective. Studies comparing the three perspectives on satisfaction with (transitional) care for different chronic conditions, however, are lacking. The main aim of this paper was to explore differences and similarities in perspectives between adolescents with chronic conditions, their parents and providers on transitional care. A secondary aim was to explore the extent to which such perspectives are disease‐specific. Methods This quantitative study included 127 adolescents with juvenile rheumatoid arthritis (JRA), neuromuscular disorder with chronic ventilation (NMD), or diabetes Type I; 166 parents; and 19 care providers. To assess the experiences and perceptions of adolescents and parents on transitional care, we used the ‘Mind the Gap’ instrument. The survey for providers included a checklist of shortcomings in transitional care. Results Adolescents rate current care significantly worse than parents on opportunities to make their own decisions and be seen without parents present. Adolescents also rated providers' current social skills lower than parents. Adolescents are more satisfied than their parents about transitional care process aspects such as co‐ordination and communication between providers, but both groups indicated that the care process offers most room for improvement. Providers reported other aspects such as adolescents' lack of responsibility with regard to self‐care and parents' difficulties with ceding control to their children. When looking at the three disease groups – JRA, NMD, diabetes, we found only small differences. According to providers, shortcomings in the care process with respect to guidelines, protocols and co‐ordination are most prevalent. Conclusion Adolescents, parents and providers all report that there is room for improvement with regard to aspects of the care delivery process in transitional care. With respect to disease‐specific issues we only found small differences.     

Making use of contrasting participant views of the same encounter

Medical Education 2010: 44: 953–961 Context The practice of medicine involves many stakeholders (or participant groups such as patients, doctors and trainees). Based on their respective goals, perceptions and understandings, and on what is being measured, these stakeholders may have dramatically different viewpoints of the same event. There are many ways to characterise what occurred in a clinical encounter; these include an oral presentation (faculty perspective), a written note (trainee perspective), and the patient’s perspective. In the present study, we employed two established theories as frameworks with the purpose of assessing the extent to which different views of the same clinical encounter (a three‐component, Year 2 medical student objective structured clinical examination [OSCE] station) are similar to or differ from one another. Methods We performed univariate comparisons between the individual items on each of the three components of the OSCE: the standardised patient (SP) checklist (patient perspective); the post‐encounter form (trainee perspective), and the oral presentation rating form (faculty perspective). Confirmatory factor analysis (CFA) of the three‐component station was used to assess the fit of the three‐factor (three‐viewpoint) model. We also compared tercile performance across these three views as a form of extreme groups analysis. Results Results from the CFA yielded a measurement model with reasonable fit. Moderate correlations between the three components of the station were observed. Individual trainee performance, as measured by tercile score, varied across components of the station. Conclusions Our work builds on research in fields outside medicine, with results yielding small to moderate correlations between different perspectives (and measurements) of the same event (SP checklist, post‐encounter form and oral presentation rating form). We believe obtaining multiple perspectives of the same encounter provides a more valid measure of a student’s clinical performance.     

Beneath the surface: discovering the unvoiced concerns of older adults with type 2 diabetes mellitus

Emerging clinical guidelines recommend shared decision making to individualize drug regimens for older adults with Type 2 diabetes mellitus. While the current health education campaign for diabetes in the United States recommends physician-initiated medication-related discussions about adherence and side effects, little emphasis is placed on soliciting patient concerns. This study's aim was to explore the concerns of older adults with diabetes about the complexity of their drug regimens and to determine whether they discussed medication-related concerns with their physician. Twenty-two patients with Type 2 diabetes age 65 years and older who used five or more medications were selected from an urban academic geriatric medicine practice in the United States. In-depth semi-structured interviews were conducted to uncover participants' perceptions of multiple medication use and related discussions with providers. The predominant theme that emerged was the variability in medication-related topics that patients perceived they could discuss with their physician. While most participants described physician-initiated discussions about adherence and side effects, many did not bring up concerns about medication cost or their desire to reduce medication burden. In order to encourage greater patient involvement in medication decision making for diabetes treatment, educational messages promoting patient-physician dialogue need to take more account of patient concerns.     

Role of primary care providers in a pandemic – conflicting views and future opportunities

In pandemic situations, primary care providers may be involved in a variety of roles related to disease surveillance, diagnosis and treatment, prevention, and patient education. This commentary describes the contextual factors that may influence primary care providers’ perspectives on their pandemic roles and responsibilities. These factors include the natural evolution of the pandemic situation, with early uncertainty affecting decision-making and communication; the variation in typical practice patterns and clinical expertise across and within primary care providers; and the lack of representation of practicing primary care providers in pandemic planning and decision-making bodies.     

Getting comfortable with disability: The short- and long-term effects of a clinical encounter

BackgroundPhysicians report discomfort when interacting with patients with disabilities, which can negatively impact the quality of healthcare they provide.Objective/HypothesisAn intervention structured around a formative clinical encounter was assessed for its effectiveness in changing comfort towards treating patients with disabilities. It was predicted that this encounter would have a positive short- and long-term impact on medical students.MethodDuring the 2017–2018 academic year, 169 third-year medical students conducted a patient encounter with a person who had a disability. Students met individually with the “patient” and completed a brief social and medical history as if they were meeting a new patient to establish care. A measure of perceived comfort caring for patients with disabilities was administered to students before and after the encounter. One year after the patient encounter, 59 students were surveyed about their satisfaction and the impact of the patient encounter.ResultsThe impact of encountering people with disabilities in a clinical setting was positive, with statistically significant improvements across all items on the measure of perceived comfort. Students were highly satisfied with the experience and anticipated feeling more confident, more comfortable, less awkward, and more skilled and efficacious when encountering a person with a disability in their future practice. A thematic analysis of the one year follow-up data suggest that students valued the encounter and desired more content on disability throughout their education.ConclusionsMedical education should include dedicated exposure to persons with disabilities and a simulated patient experience allowing for a safe environment to gain skills and confidence.     

A dialogic model of conversations about risk: Coordinating perceptions and achieving quality decisions in cancer care

We propose that academic scholarship and clinical practice should conceptualize communication about risk as a dialogic and relational process. This conceptual paper addresses how clinical decisions about cancer treatment are impacted by different risk perceptions. Patients and health care providers base their risk perceptions on analytic or experiential reasoning processes. However, most risk communication research in the clinical context only examines the transmissive and persuasive communication of these different risk perceptions. This transmissive communication results in a monologic model that limits the opportunities for patients and clinicians to incorporate their perspectives into a shared understanding. The dialogic model of risk communication contributes to a quality cancer care decision because it creates open space to find connections between patient values and clinical evidence while allowing the parties to have a satisfactory level of involvement. The final section of the paper describes theory behind a dialogic perspective and offers guidelines for how to implement it in risk communication to improve clinical decision making.     

Negotiation and the structure of discourse in medical consultation

Using audio tape recordings of consultations between mid-level providers and patients in a health maintenance organization, a model of medical negotiation is presented. This model conceptualizes negotiation as a process in which mid-level providers and patients introduce their perspectives on the definition and treatment of medical problems by linking together units of discourse (acts, turns, sequences and phases). This model clearly locates negotiation in observable activities of interactants and demonstrates how the process changes over the course of an encounter as provider and patient participate in the taking of a medical history, the performance of a physical examination, and the discussion of the problem and treatment. Because of the formal yet flexible nature of this model, it lends itself for use in comparative studies of medical practitioner-patient negotiation.     

GPs' strategies in intercultural clinical encounters

BACKGROUND: In North America and Europe, patients and physicians are increasingly likely to come from non-Western cultural backgrounds. The expectations of these patients may not match those of physicians. OBJECTIVE: To identify strategies used by GPs with patients from cultures other than their own. METHODS: We conducted a qualitative inductive study based on 25 semi-structured interviews with family physicians practising in Montreal, Canada. We elicited physicians' strategies when dealing with patients from a cultural background different from their own. We began by asking physicians to describe an encounter they found difficult and one they found easy. RESULTS: Physicians reported three types of strategies: (i) insistence on patient adaptation to local beliefs and behaviours; (ii) physician adaptation to what he or she assumed patients wanted; and (iii) negotiation of a mutually acceptable plan. Individual physicians did not adopt the same strategy in all situations. Their choice of strategy depended on the topic. When dealing with issues they felt deeply about, such as the autonomy of women, many physicians insisted on patient adaptation. Physicians used a patient-centred model of care, but had no framework to elicit information about patients' culture. CONCLUSIONS: A patient-centred model of care enables physicians to consult effectively despite a wide range of cultural differences between themselves and their patients. However, their lack of a conceptual framework for addressing cultural difference prevents systematic data collection and consideration of challenges to respect for individual autonomy. Physician training should include the provision of an explicit conceptual framework for approaching patients from a different culture.     

MM6 Decision Analysis: What is its Utility for Pharmacoeconomic Analysis?

This session is intended for sharing and comparing computer software applications for research, management, and practice. Software applications will be demonstrated for decision analysis, cost effectiveness analysis, multiattribute utility computation, and assessing patient utilities. Desktop applications, will be discussed. Laptop and handheld computer software will be demonstrated. Pharmacoeconomic software allows data to be analyzed from different perspectives: patient, provider, hospital, managed care, and society. Software models also allow assessment of health care products or services from different quantitative perspectives: cost of illness, cost minimization, cost-benefit, cost-effectiveness, and cost-utility. The integration of decision analysis and spreadsheets will also be discussed. Software is utilized to collect information, analyze data, present findings, or educate managers, providers and patients. Pros and cons of each analytical and software approach will be discussed. Participants are encouraged to bring their own laptops to demonstrate their own software or related Internet offerings in an informal roundtable fashion. Software beta versions allowed; "viruses" discouraged.     

The origins of medical evidence: Communication and experimentation

BACKGROUND: The experimental method to acquire knowledge about efficacy and efficiency of medical procedures is well established in evidence-based medicine. A method to attain evidence about the significance of diseases and interventions from the patients' perspectives taking into account their right to self-determination about their lives and bodies has however not been sufficiently characterized. DESIGN: Identification of a method to acquire evidence about the clinical significance of disease and therapeutic options from the patients' perspectives. ARGUMENTS: Communication between patient and physician is analyzed as the method to attain evidence about what is at stake for individual patients in disease and therapy. It is the method that enables physicians to directly take into account patients' disease experiences and their aims regarding treatments. These patients' perspectives in turn determine the clinical significance of diagnoses and therapeutic options, if patient-autonomy is taken seriously. CONCLUSIONS: A full account of evidence-based medicine needs to include experimentation and communication between physician and patient as equally important methods to attain evidence necessary to practice patient-oriented medicine. The communicative method is especially important for primary physicians as they direct patients within the medical system to have their medical problems most effectively and efficiently addressed.     

Quality-of-Care Indicators for HIV/AIDS

As care for HIV/AIDS becomes more concentrated within specific providers and organisations, it would be useful to have indicators to describe the quality of care. This paper reviews concepts related to quality of care, and practical issues including sampling and risk adjustment. Indicators can be collected using a combination of administrative, chart review and survey data to reflect clinical, patient and societal perspectives. We suggest that for adults with HIV/AIDS, indicators might include measures of health status and patient satisfaction, and essential care processes. Health status measures could include CD4+ T-lymphocyte count and HIV-RNA, progression to AIDS, symptom scores, health-related quality of life scores, patient utility and disability days. Essential care processes could include receipt of acceptable antiretroviral treatment, CD4+ and HIV-RNA monitoring, screening for opportunistic infections, prophylaxis against Pneumocystis carinii pneumonia, handling of symptoms and pneumococcal vaccination. For those at increased risk for HIV, potential indicators include screening for HIV risk behaviours and HIV testing. Data from indicators such as these could be used by individuals to select among providers, purchasers of care to select among health plans and payors to hold provider groups accountable. In addition, data could be used by groups of providers to improve the quality of care.     

Same description,different values. How service users and providers define patient and public involvement in health care

Background Patient and public involvement in health care is important, but the existing definitions of the concept do not integrate the stakeholders’ own perceptions. Objective To investigate and compare service users’ and service providers’ own definitions of patient and public involvement and their implications. Design, setting and participants Qualitative study with mainly individual in‐depth semi‐structured interviews conducted between June 2007 and June 2009. Data were analysed using a grounded theory approach. Results A total of 20 patients, 13 public representatives and 44 health service providers/managers in both somatic and mental health care were interviewed. A common definition of patient and public involvement emerged: It is founded on mutual respect, carried out through dialogue aiming at achieving shared decision making. Nevertheless, users and providers assigned different values to the core aspects: Respect was imperative for service users and implied for providers, dialogue was a way to gain respect for service users and to achieve good outcome for providers, and both worried that the other party wanted to make sole decisions. Conclusions Users and providers need to consider that although they have a common definition of involvement in health care, they assign different values to its aspects. Increasing and improving patient and public involvement therefore requires knowledge on and dialogue between the parties about these differences.     

Development of instruments to measure the quality of breast cancer treatment decisions

Background Women with early‐stage breast cancer face a multitude of decisions. The quality of a decision can be measured by the extent to which the treatment reflects what is most important to an informed patient. Reliable and valid measures of patients’ knowledge and their goals and concerns related to breast cancer treatments are needed to assess the decision quality. Objective To identify a set of key facts and goals relevant to each of three breast cancer treatment decisions (surgery, reconstruction and adjuvant chemotherapy and hormone therapy) and to evaluate the validity of the methods used to identify them. Methods Candidate facts and goals were chosen based on evidence review and qualitative studies with breast cancer patients and providers. Cross‐sectional surveys of patients and providers were conducted for each decision. The accuracy, importance and completeness of the items were examined. Results Thirty‐eight facts (11–14 per decision) and 27 goals (8–10 per decision) were identified. An average of 17 patients and 21 providers responded to each survey. The sets of facts were accurate and complete for all three decisions. The sets of goals and concerns were important for surgery and reconstruction, but not chemotherapy/hormone therapy. Patients and providers disagreed about the relative importance of several key facts and goals. Conclusions Overall, breast cancer patients and providers found the sets of facts and goals accurate, important and complete for three treatment decisions. Because patients’ and providers’ perspectives are different, it is vital that instrument development should include items reflecting both views.     

Patient perceptions of carrying their own health information: approaches towards responsibility and playing an active role in their own health – implications for a patient‐held health file

Objective To elicit patients’ views on whether they could contribute to improvements in their care by carrying their own health information to clinician encounters; and to consider the implications for the development of a patient‐held health file (PHF). Background Increasing rates of chronic disease lead to health care being delivered by multiple care providers often at distributed geographic locations. As a way of increasing the availability of patient information to care providers our project will trial a PHF. Patients carry these files to doctors’ appointments where clinicians record data for other doctors or the patient. Increasing the availability of patient information is anticipated to enhance the safety and quality of care delivery and improve health outcomes. Study design Qualitative semi‐structured interviews were conducted with 10 patients. Participants were evenly distributed in terms of gender, aged 60 years or greater and visited at least two specialists and one general practitioner. Findings In this exploratory study, patients who were currently active in decision making about their own health already recorded some health information. They were receptive to carrying their information and thought they should take some responsibility for their health. Patients who were more passive in making decisions about their health did not perceive a need to carry their own information and felt that their doctors communicated adequately. Conclusion Patient‐held health files provide an opportunity for patients to access their health information. Such files have the potential to improve health outcomes for patients who adopt both active and passive roles in relation to their own health and engaging with their health information.     

Two studies of good clinical judgment

There is a continuing controversy about the quality of unaided clinical judgment. This paper reports two studies that show that experienced medical providers made accurate probability assessments and applied those assessments to patient care in a manner consistent with principles of optimal decision making. In the first study, experienced clinicians and physician assistants accurately judged the relative frequency of three cough-related diagnoses in an outpatient population, suggesting that their encounter with several "unrelated" diagnostic problems does not interfere with their ability to judge accurately the frequency of any single diagnostic problem. In the second study, a group of clinicians assessed the probability that each patient seen in an outpatient clinic had pneumonia. Physicians were more likely to assign a pneumonia diagnosis and to order a radiograph for patients with a greater assessed probability of pneumonia (p less than 0.05). Most of the physicians appeared to use cutoff probabilities or "thresholds" above which they acted as though the patient had the disease and below which they acted as though the patient did not have the disease, consistent with rational decision-making principles. However, the threshold probabilities being used were quite different from physician to physician, implying that the physicians managed the patient population in a nonuniform manner. Thus it may be desirable to supplement "good" clinical judgment with decision aids to ensure standardized medical care.     

A brief office-based intervention to facilitate diabetes dietary self-management

There is a pressing need for brief, practical interventions that address diabetes management. We have developed an office-based intervention to prompt both patients and providers to focus on behavioral issues relevant to dietary self-management that is being evaluated in a randomized trial. The intervention is designed to be broadly applicable to the majority of adult diabetes outpatients during medical visits; uses touchscreen computer assessment to provide immediate feedback on key issues to patients and providers just prior to their interaction; and provides goal setting and problem-solving assistance to patients following their meeting with the physician. Follow-up components include phone calls and videotape or interactive video instruction as needed. The program is described, and demographic and behavioral characteristics of participants are presented for the first 95 patients randomized. Initial process results suggest success in producing modest, targeted behavior changes among a broad cross-section of patients. If the long-term results are equally positive, this intervention could provide a prototype for a feasible, cost-effective way to integrate patient views and behavioral management into office-based care for diabetes.