Improved Diabetes Control Through a Provider-Based Disease Management Program

Objective: The primary aim of this study was to evaluate the effectiveness of a newly implemented hospital-based diabetes mellitus disease management program. A secondary aim was to determine if relationships existed among variables.Design and setting: Effectiveness was evaluated in terms of glycemic control, post-program acute care resource utilization, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life. Participants in the Diabetes LifeCare program (DLC) received all standards of care which included diabetes self-management education, medical management by a primary care provider (PCP) supported by an evaluation and recommendations by an Advanced Practice Registered Nurse (APRN), nutritional counseling and at minimum, quarterly follow-up appointments for 1 year.Patients: Patients who were aged ≥18 years and referred to the DLC program with new a diagnosis or history of type 1 or 2 diabetes mellitus.Main outcome measures and results: Results demonstrated that at 3 months after enrollment in the DLC, participants in the study with available data (n = 142) had a mean decrease in predominant glycosylated hemoglobin (HbA_1c) values from 9.31 to 7.21 (p < 0.001). The HbA_1c value for participants with data at the 6-month visit (n = 66) decreased from 9.23 to 7.22 at 3 months and to 6.80 at 6 months (p < 0.001). At baseline, 52 of the 142 participants (36.5%) had HbA1c values less than 8.0, compared with 107 patients (75.4%) at 3 months (p < 0.0001). A total of 185 of 227 patients (81.5%) received eye examinations as per ADA guidelines. A total of 225 of 227 patients (99.1%) were in compliance with the ADA guidelines for nutritional counseling as a result of participation in the program. On the Physical Component Summary, their mean scores were 42.75 [standard deviation (SD) = 11.17] at enrollment, compared with 45.12 (SD = 10.52) at 3 months (p < 0.001). The Mental Component Summary score increased from 47.52 (SD = 11.90) to 50.83 (SD = 10.47) [p < 0.001]. Regarding resource utilization, during the follow-up period only 3 of 227 patients had emergency room visits and there were no inpatient visits for acute problems related to diabetes.Conclusions: Our results show that, in the short term, significant improvement in glycemic control can be achieved through a comprehensive program of patient education and management, that includes collaborative efforts with the patient’s primary care provider. High rates of eye and foot examination can also be attained by reinforcing patient involvement and admissions for acute metabolic complications can be minimized.     

治疗耐甲氧西林金黄色葡萄球菌感染的抗菌药物新进展

青霉素做为第一种抗菌药物,它的发现是人类医药史上最重大的发现之一,人类曾欣喜的认为细菌感染疾病已成历史.但时隔不久,各种耐药菌便被检出.自1961年英国发现第1株耐甲氧西林金黄色葡萄球菌(MRSA)之后,它便在世界各国的医疗单位中传播开来,成为医院感染如医院获得性肺炎(HAP)、呼吸机相关性肺炎(VAP),甚至成为社区获得性肺炎(CAP)的主要病原菌,增加了患者的病死率、住院时间和医疗费用[1].     

春来宝宝防过敏

周末下午,随着急促的脚步声和喊声,一对年轻父母抱着一个烦躁不安、憋得小脸通红的孩子,跑到医生面前。医生一边询问病史,一边迅速做详细的身体检查,同时指挥护士进行相应的治疗。吸氧、雾化吸入治疗、静脉输液……经过一系列紧张有序的治疗,孩子安静了下来,面色转为红润,呼吸均匀,可以正常地与爸爸妈妈进行交谈了,甚至渐渐又恢复到以前的顽皮状态。家长在高兴的同时向医生提出了问题：“我的孩子患的是什么病？为什么会出现这种状况？今后如何预防？”     

Impact of a Diabetes Disease Management Program by Race and Ethnicity

Background

In the US, diabetes mellitus affects people in all racial and ethnic groups, but the prevalence and risk of complications are considerably higher among African Americans, Hispanics, American Indians, and Alaskan Natives. This study aimed to evaluate the impact of enrollment for at least 1 calendar year in a diabetes disease management program (DDMP) in a large, commercially insured, managed care population. We assessed changes in utilization of preventive services and adoption of diabetes self-management behaviors by race and ethnicity.

Methods

Participants were aged >17 years and had type 1 or 2 diabetes. They were enrolled in a targeted, high-risk level DDMP between January 2003 and September 2003 and were enrolled in the managed care organization (MCO) for a 2-year period beginning 1 year prior to their enrollment in the DDMP. At baseline, 19 483 MCO enrollees who were participating in the targeted high-risk level DDMP were mailed a 40-item, self-administered baseline survey, which took between 10 and 15 minutes to complete. Baseline results are reported elsewhere. One year later, in June 2004, 5174 of the baseline responders were mailed a slightly modified version of the 40-item survey. The survey measured use of eight preventive services (cholesterol test, dental examination, dilated eye examination, urinalysis, foot examination, influenza vaccination, pneumococcal vaccination, and glycated hemoglobin testing) and engagement in four self-management behaviors (blood glucose tests, diet monitoring, exercise, and smoking avoidance).

Results

Of the 5174 follow-up surveys mailed, 1961 (37.9%) were eligible for comparative analysis. Blacks and Hispanics reported more annual healthcare visits (average of 6.2 and 6.5, respectively) compared with Whites (average of 5.0, p < 0.0001). However, at follow-up, both Blacks and Hispanics had lower utilization rates than Whites for six of the eight preventive services that were measured. At follow-up, both Blacks and Whites were more likely than at baseline to report up-to-date status of influenza and pneumococcal vaccination (p ≤ 0.0001). At follow-up, the racial/ethnic gap in self-management behaviors that was observed at baseline had reduced and in fact had reversed direction for glucose tests, as Blacks were more likely than Whites to routinely test their blood glucose.

Conclusions

These data indicate that DDMP enrollment for at least 1 calendar year had a mixed impact on overall diabetes behaviors and on racial/ethnic disparities in preventive services utilization and self-management behaviors. Further studies are needed to give a clearer understanding of why some diabetic MCO enrollees are less likely to use preventive services, and why disparities remain even in settings where healthcare services are universally available.

     

糖尿病患者自我管理研究进展

糖尿病患者自我管理作为一种以提高患者自我效能、强调患者主动承担疾病管理责任的新型保健服务模式已受到了国内外研究者的关注。该文从患者自我管理概念和理论基础出发,综合描述了糖尿病患者自我管理的内容和形式、主要模式和教育标准,国内外研究现状和效果评价,并对目前存在的问题作简要分析。     

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.     

某高炉改建职业病危害控制效果监测评价

目的评价高炉改建项目的职业病危害控制效果。方法根据现场职业卫生学调查和现场作业场所有害因素测试结果,对本项目职业病危害控制效果进行综合分析与评价。结果除3#振动筛和皮带巡检工岗位检查超过PC-STEL外,其它粉尘检测均合格。另因防护设施密封效果原因致液压炮操作室、渣沟出渣处CO和SO2浓度超过PC-STEL,其它毒物浓度符合国家标准。结论项目职业病危害控制效果基本符合国家规定,应对个别尘毒超标岗位的防护设施进行改造完善,并且设置规范的职业病危害警示标识,加强个体防护。     

Design,Development and Implementation of a Multidisciplinary Diabetes Disease Management Programme

Disease management initiatives are becoming increasingly popular in the US as a way for managed-care plans to care for their members with chronic conditions. Diabetes is one of the most expensive chronic conditions, both in terms of human lives and actual healthcare costs. Managed-care plans are adopting different approaches to caring for their members with diabetes. The experience of one organisation shows that a population management approach to caring for people with diabetes is the best way to improve clinical outcomes and reduce healthcare costs for managed-care organisations in the short term.     

糖尿病是一种心血管疾病和心身疾病的观点探讨

本文就糖尿病患者最早就诊的是心血管内科医师,以及负性情绪可明显影响糖尿病的发展进行了分析,并提出改善心境可明显增加自我控制糖尿病的能力。     

糖尿病血糖监测方法研究进展

血糖监测在医疗中主要的目的就是及时地反馈患者的饮食、运动以及药物治疗的效果。糖尿病患者长年受到自身生活习惯以及行为的直接影响,医疗机构对糖尿病患者的治疗需要结合患者的实际生活情况配合医疗药物等,并让患者做好自我管理,这些都有助于糖尿病患者的疾病控制。而糖尿病血糖监测则是患者进行自我管理的主要工具,其对患者的康复起到了重要的作用。     

抗生素引起腹泻病流行的进展

腹泻病是我国传染病中发病数最多、流行面最广的一组疾病 [1 ] 。有 70 0多种药引起腹泻 ,约占所有药物不良反应的7% ,其中 2 5 %是由抗生素引起的 [2 ]。几乎所有的抗生素都可通过胃肠道的分泌、消化、吸收和运动等功能障碍 ,引起腹泻病 ,其中青霉素类、头孢菌素类、克林霉素发生率较高 [3,4 ] 。　　抗生素引起腹泻 ,分为急性和慢性两种。急性腹泻出现在几小时至几天内 ,慢性腹泻出现在几周甚至几年后 ,因此临床对慢性腹泻很难判别是否由抗生素引起 ,而且临床一般不采用内窥镜和活检来区分病因 ,所以患者的医疗史、药物史显得更为重要。两…