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

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

Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: To examine racial/ethnic and socioeconomic variation in diabetes care in managed-care settings. RESEARCH DESIGN AND METHODS: We studied 7,456 adults enrolled in health plans participating in the Translating Research Into Action for Diabetes study, a six-center cohort study of diabetes in managed care. Cross-sectional analyses using hierarchical regression models assessed processes of care (HbA(1c) [A1C], lipid, and proteinuria assessment; foot and dilated eye examinations; use or advice to use aspirin; and influenza vaccination) and intermediate health outcomes (A1C, LDL, and blood pressure control). RESULTS: Most quality indicators and intermediate outcomes were comparable across race/ethnicity and socioeconomic position (SEP). Latinos and Asians/Pacific Islanders had similar or better processes and intermediate outcomes than whites with the exception of slightly higher A1C levels. Compared with whites, African Americans had lower rates of A1C and LDL measurement and influenza vaccination, higher rates of foot and dilated eye examinations, and the poorest blood pressure and lipid control. The main SEP difference was lower rates of dilated eye examinations among poorer and less educated individuals. In almost all instances, racial/ethnic minorities or low SEP participants with poor glycemic, blood pressure, and lipid control received similar or more appropriate intensification of therapy relative to whites or those with higher SEP. CONCLUSIONS: In these managed-care settings, minority race/ethnicity was not consistently associated with worse processes or outcomes, and not all differences favored whites. The only notable SEP disparity was in rates of dilated eye examinations. Social disparities in health may be reduced in managed-care settings.     

A systematic approach to risk stratification and intervention within a managed care environment improves diabetes outcomes and patient satisfaction

OBJECTIVE--To determine whether a comprehensive diabetes management program that included risk stratification and social marketing would improve clinical outcomes and patient satisfaction within a managed care organization (MCO). RESEARCH DESIGN AND METHODS--The 12-month prospective trial was conducted at primary care clinics within a MCO and involved 370 adults with diabetes. Measurements included 1) the frequency of dilated eye and foot examinations, microalbuminuria assessment, blood pressure measurement, lipid profile, and HbA(1c) measurement; 2) changes in blood pressure, lipid levels, and HbA(1c) levels; and 3) changes in patient satisfaction. RESULTS--Complete data are reported for the 193 patients who had been enrolled for 12 months; life table analysis is reported for all patients who remained enrolled at the study's end as well as for a comparative control group of 623 patients. For the 193 patients for whom 12-month data were available, the number of patients in the low-risk category (HbA(1c) <7%) increased by 51.1%. A total of 97.4% of patients with an HbA(1c) >8% at baseline had a change in treatment regimen. Patients at the highest risk for coronary heart disease (LDL >130 mg/dl) decreased from 25.4% at baseline to 20.2%. Patients with a blood pressure <130/85 mmHg increased from 23.8 to 44.6%. Of these patients, 63.0% had changes in medication. Patients and providers expressed significant increases in satisfaction with the program. CONCLUSIONS--The program was successful in initiating the recommended changes in the diabetic therapeutic regimen, resulting in improved glycemic control, increased monitoring/management of diabetic complications, and greater patient and provider satisfaction. These results should have great significance in the design of future programs in MCOs aimed at improving the care of people with diabetes and other chronic diseases.     

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

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

The effectiveness of hospital-based diabetes case management: an example from a northern Taiwan regional hospital

The aim of this study was to design, implement and evaluate disease outcomes at a regional hospital- based case management program of care for patients with type 2 diabetes. A medical team and practice guidelines were established in line with the health insurance strategy of Taiwan's Bureau of National Health Insurance (BNHI) and American Diabetes Association (ADA) Standards of Care for Diabetes (2003 edition). Also, a set of self-care booklets was designed suitable for use by the subject group. The study was prospective and followed the patients from enrollment to one year. Patient outcomes were determined based on laboratory examinations and recorded self-care behavior. Data were collected at enrollment and over 4 follow-up times within a one year period. Generalized Estimating Equation (GEE) multiple linear regression and logistic regression were used for repeated measurements and adjustments of the effects of specific prognostic factors. Sixty subjects diagnosed with type 2 diabetes (mean duration 3.25 years) were recruited. All participants were married with a mean age of 52.5 years. A majority (58.3%) was male and 65% were ethnic Hakka. Self-care knowledge and behavior accomplishment rates were: taking medications by oneself, 91.3% (knowing medicines, 25.4%); hypoglycemia management, 23.3%; monitoring blood sugar, 46.7%; exercise, 35.8%; diet management, 51.7% and foot care, 92.8%. Significantly improved ADA diabetes care standard items included HbA1C (p< .0001), fasting glucose (p< .01) and triglycerides (p< .05). The study incorporated evidence-based guidelines, public health insurance strategies and self-care booklets into a protocol to provide comprehensive care. The implemented diabetes program achieved diabetes care goals and improved patient self-care.     

Impact of a program to improve adherence to diabetes guidelines by primary care physicians

OBJECTIVES: Previous studies have shown that primary care physician (PCP) adherence to diabetes guidelines is suboptimal. We sought to determine the state of diabetes care given by independently practicing PCPs in a rural county in Indiana and whether a multifaceted intervention targeting PCPs, patients, and the health care system would improve adherence to diabetes guidelines. RESEARCH DESIGN AND METHODS: Baseline audits to assess adherence to diabetes guidelines were done on charts of the seven PCPs in the county. Audits were repeated after development of local consensus guidelines and feedback of baseline performance and after implementation of various interventions (practice aids, physician detailing, patient education sessions, and implementation of computerized individual meal planning). RESULTS: Before any intervention, rates of adherence to guidelines were low (15% for foot exams, 20% for HbA(1c) measurement, 23% for eye exam referrals, 33% for urine protein screening, 44% for lipid profiles, 73% for home glucose monitoring, and 78% for blood pressure measurements). One year after development of local consensus guidelines and feedback of baseline performance, significant improvements were seen in blood pressure measurements (71 vs. 83%; P = 0.002), foot exams (19 vs. 42%; P < 0.001), HbA(1c) measurements (26 vs. 37%; P = 0.012), and PCP eye exams (38 vs. 46%; P = 0.043); a trend toward improvement was seen in referral to eye specialists (25 vs. 33%; P = 0.059). After a second year of multiple interventions, only blood pressure measurements (70 vs. 92%; P < 0.001) and foot exams (22 vs. 47%; P < 0.001) remained significantly improved; all other areas returned to rates indistinguishable from baseline. CONCLUSIONS: In busy primary care practices lacking organizational support and computerized tracking systems, sustained improvements in diabetes care are difficult to attain using traditional physician-targeted approaches.     

Quality of care for patients diagnosed with diabetes at screening

OBJECTIVE: Screening for diabetes has the potential to be an effective intervention, especially if patients have intensive treatment of their newly diagnosed diabetes and comorbid hypertension. We wished to determine the process and quality of diabetes care for patients diagnosed with diabetes by systematic screening. RESEARCH DESIGN AND METHODS: A total of 1,253 users of the Durham Veterans Affairs Medical Center aged 45-64 years who did not report having diabetes were screened for diabetes with an HbA(1c) test. All subjects with an HbA(1c) level > or =6.0% were invited for follow-up blood pressure and fasting plasma glucose (FPG) measurements. A case of unrecognized diabetes was defined as HbA(1c) > or =7.0% or FPG > or =126 mg/dl. For each of the 56 patients for whom we made a new diagnosis of diabetes, we notified the patient's primary care provider of this diagnosis. One year after diagnosis, we reviewed these patients' medical records for traditional diabetes performance measures as well as blood pressure. Follow-up blood pressure was also ascertained from medical record review for all subjects with HbA(1c) > or =6.0% who did not have diabetes. We compared blood pressure changes between patients with and without diabetes. RESULTS: Among patients diagnosed with diabetes at screening, 34 of 53 (64%) had evidence of diet or medical treatment for their diabetes, 42 of 53 (79%) had HbA(1c) measured within the year after diagnosis, 32 of 53 (60%) had cholesterol measured, 25 of 53 (47%) received foot examinations, 29 of 53 (55%) had eye examinations performed by an eye specialist, and 16 of 53 (30%) had any measure of urine protein. The mean blood pressure decline over the year after diagnosis for patients with diabetes was 2.3 mmHg; this decline was similar to that found for 183 patients in the study without diabetes (change in blood pressure, -3.6 mmHg). At baseline, 48% of patients with diabetes had blood pressure <140/90, compared with 40% of patients without diabetes; 1 year later, the same 48% of patients with diabetes had blood pressure <140/90, compared with 56% of patients without diabetes (P = 0.31 for comparing the change in percent in control between groups). CONCLUSIONS: Patients with diabetes diagnosed at screening achieve less tight blood pressure control than similar patients without diabetes. Primary care providers do not appear to manage diabetes diagnosed at screening as intensively as long-standing diabetes and do not improve the management of hypertension given the new diagnosis of diabetes.     

Quality of care for uninsured patients with diabetes in a rural area

OBJECTIVE: We compared quality of care for uninsured patients with diabetes in private physician offices and community/migrant health centers (C/MHCs). RESEARCH DESIGN AND METHODS: We conducted a cross-sectional medical record review in a convenience sample of eight physician offices and three C/MHC sites in rural North Carolina. Billing systems generated lists of self-pay patients with diabetes. Abstraction of the medical records (n = 142) yielded data on process and intermediate outcome measures of diabetes care, which were derived from the Diabetes Quality Improvement Project. RESULTS: Medical records of patients in C/MHCs demonstrated higher rates on four of six process measures of quality of care, including measurement of HbA(1c) (98 vs. 75%; P < 0.001), cholesterol (82 vs. 51%; P < 0.001), and urine protein (90 vs. 25%; P < 0.001). Nonsignificant trends in documented eye examinations and the intermediate outcome of blood pressure control were found in medical records of C/MHC patients. No differences were seen in the intermediate outcomes of glucose or lipid control. Notable differences in provider type, time since training, and use of flow sheets were found. CONCLUSIONS: In our sample, uninsured patients with diabetes in C/MHCs had higher quality of care as suggested by higher rates of processes of care. Outcomes were similar in the two settings and well below targets. Further work is required to replicate these findings and to understand which features of C/MHCs may facilitate quality care for the uninsured and are replicable in other settings.     

What do internal medicine residents need to enhance their diabetes care?

OBJECTIVE: To identify areas that should be targeted for improvement in care, we examined internal medicine resident practice patterns and beliefs regarding diabetes in a large urban hospital outpatient clinic. RESEARCH DESIGN AND METHODS: Internal medicine residents were surveyed to assess the frequency at which they performed key diabetes quality of care indicators. Responses were compared with recorded performance derived from chart and laboratory database reviews. Resident attitudes about diabetes were determined using the Diabetes Attitude Survey for Practitioners. Finally, an eight-item scale was used to assess barriers to diabetes care. RESULTS: Both self-described and recorded performance of recommended diabetes services short of national recommendations. For yearly eye examinations and lipid screening, recorded performance levels were similar to trainees' reports. However, documented inquiries about patient self-monitoring of blood glucose, performance of foot examinations, and urine protein screening were lower than trainees' reports. Some 49% of the residents selected a target HbA1c of 6.6-7.5% as an attainable goal, yet half of the patients using oral agents or insulin had HbA1c values > 8.0%. No differences in self-described or recorded performance were found by year of training. Most residents did not perceive themselves to need additional training related to diabetes care, and residents were generally neutral about patient autonomy. Patient nonadherence and time constraints within the clinic were most often cited as barriers to care. CONCLUSIONS: The study identifies several areas that require improvement in resident care of diabetes in the ambulatory setting. Because experience during training contributes to future practice patterns, developing a program that teaches trainees how to implement diabetes practice guidelines and methods to achieve optimal glycemic control may be key to future improvements in the quality of diabetes care.     

One-year clinical outcomes for Louisiana residents diagnosed with type 2 diabetes and hypertension

PURPOSE: To identify patient outcomes for residents with a dual diagnosis of diabetes and hypertension under the care of nurse practitioners and physicians in joint or collaborative practice in Louisiana. DATA SOURCES: A retrospective review of records of 115 patients by 15 NPs across the state (response rate 30%) that examined clinical outcomes after 1 year for 14 indexes of care as well as standards of treatment for both diabetes and hypertension. CONCLUSIONS: Significant clinical outcomes for body mass index, blood pressure, hemoglobin A1c, fasting glucose, and total cholesterol levels were found. Clinical outcomes were correlated with healthcare interventions including appropriate medications, use of diabetes educators, and home glucose monitoring as well as total number of visits to the healthcare provider. IMPLICATIONS FOR PRACTICE: Improved outcomes for patients with a dual diagnosis of diabetes and hypertension can be enhanced by the use of diabetes educators, home glucose monitoring, and frequent visits to the healthcare providers. More research is needed to measure the contribution of NPs to improved health outcomes.     

The managed care contract: survival or closure?

The managed health care contract can be considered the most powerful tool in the health care environment today. Providers of care as well as insurers need to fully comprehend the legal and financial impact of these contracts. Too many organizations (providers and insurers) are getting caught in financial failure, resulting in bottom line-driven health care. It seems that the days of providing the most ethically appropriate health care are gone. Too much emphasis has been put on providers and administrators to provide the care that will result in positive income. The only way to "protect" oneself is in the creation, negotiation, and administration of the managed health care contract.     

Long-Term Pain and Recovery After Major Pediatric Surgery: A Qualitative Study With Teens,Parents, and Perioperative Care Providers

Research developing targeted treatment focused on coping with children's long-term pain after surgery is needed because of the high prevalence of chronic pain after surgery. This qualitative study aimed to: 1) understand the child's and family's experiences of pain over the course of their surgical experience, and 2) gather stakeholder input regarding potential barriers and facilitators of perioperative intervention delivery. Fifteen children ages 10 to 18 years who underwent recent major surgery, their primary caregivers, and 17 perioperative health care providers were interviewed. Interviews were coded using semantic thematic analysis. The perioperative period presented emotional challenges for families. Families felt unprepared for surgery and pain. Recovery and regaining physical functioning at home was challenging. Families struggled to return to valued activities. Families reported interest in a perioperative psychosocial intervention. Providers endorsed that families would benefit from enhanced coping skills. They emphasized that families would benefit from more detailed preparatory information. Providers suggested that flexible intervention delivery at home would be ideal. Research developing interventions addressing pain and anxiety in children undergoing major surgery is critically needed. The findings of the present study can inform intervention development with the aim of improving short- as well as long-term recovery in children undergoing major surgery.

晚期癌症患者居家姑息照护服务影响因素的质性研究

目的 深入了解晚期癌症患者居家姑息照护服务现状及其影响因素,为规范发展居家姑息照护服务提供参考.方法 采用现象学研究方法,对10名社区卫生服务中心的医护人员进行非结构访谈,用现象学分析法进行资料分析.结果:社区卫生服务中心为晚期癌症患者开展定期随访、家庭病床、临时出诊等居家姑息服护服务,有待进一步拓展与完善;归纳影响居家姑息照护服务开展的3个主题为政策环境因素、服务供方因素、服务需方因素.结论:居家姑息照护服务的开展需要政策支持,完善杜区卫生服务和提高公众信任与理解.     

Out-of-pocket costs and diabetes preventive services: the Translating Research Into Action for Diabetes (TRIAD) study

OBJECTIVE: Despite the increased shifting of health care costs to consumers, little is known about the impact of financial barriers on health care utilization. This study investigated the effect of out-of-pocket expenditures on the utilization of recommended diabetes preventive services. RESEARCH DESIGN AND METHODS: This was a survey-based observational study (2000-2001) in 10 managed care health plans and 68 provider groups across the U.S. serving approximately 180,000 patients with diabetes. From 11,922 diabetic survey respondents, we studied the occurrence of self-reported annual dilated eye exams and diabetes health education and among insulin users, daily self-monitoring of blood glucose (SMBG). Conditional probabilities were estimated for outcomes at each level of self-reported out-of-pocket expenditure by using hierarchical logistic regression models with random intercepts. RESULTS: Conditional probabilities of utilization (95% CI) varied by expenditure for dilated eye exam [no cost 78% (75-82), copay 79% (75-82), and full price 70% (64-75); P < 0.0001]; diabetes health education [no cost 29% (23-36), copay 29% (23-36), and full price 19% (14-25); P < 0.0001]; and daily SMBG [no cost 75% (68-81), copay 68% (60-75), and full price 59% (49-68); P < 0.0001]. Extensive adjustment for patient factors had no discernible effect on the estimates or their significance, and cost-utilization relationships were similar across income levels and other patient characteristics. CONCLUSIONS: Benefit packages structured to derive greater fiscal contribution from the health plan membership result in suboptimal use of diabetes preventive services and may thus lead to poorer clinical outcomes, greater future costs, and lower health plan quality ratings.     

配对血糖监测方案干预对糖尿病患者疾病自我管理能力的效果评价

目的探讨配对血糖监测方案对糖尿病患者疾病自我管理能力及血糖控制水平的影响。 方法以2017年1月至2018年6月在北京大学第一医院糖尿病共同照护门诊规律就诊（频率为每3个月一次复诊）一年以上的患者为研究对象,进行干预前后分析。分别在患者初诊及随访1年后测定糖化血红蛋白（HbA1c）、身高、体质量,计算体质量指数（BMI）,并使用《糖尿病自我管理行为量表6》评价其自我管理能力。于患者初诊时指导患者居家进行餐前餐后配对血糖监测,并依据监测结果适当调整饮食、运动等活动。于1年诊时,调查患者就诊前1个月平均每周实际配对血糖监测频次。采用Wilcoxon检验比较不同配对监测频次患者在自我管理能力评分各方面（饮食、运动、自我血糖监测、遵医嘱血糖监测、足部护理和用药）的差异。采用t检验比较不同配对监测频次组间BMI及HbA1c的差异。 结果符合入选标准并完成数据收集及量表评估的患者共153例。1年诊就诊前1个月内,平均每周配对血糖监测<1次的患者86例为非配对监测组,配对血糖监测≥1次的患者67例为配对监测组。1年诊时,配对监测组与非配对监测组在饮食［7.00（5.00~7.00）分vs 5.00（3.00~7.00）分］、自我监测血糖［4.50（2.00~7.00）分vs 2.00（0.25~4.00）分］及遵医嘱血糖监测［5.00（2.00~7.00）分vs 2.00（0~3.75）分］方面比较得分均较高,差异均具有统计学意义（Z=-2.663,P=0.008;Z=-3.851,P<0.001;Z=-3.892,P<0.001）;在运动、足部护理及用药方面得分比较,差异均无统计学意义（P均>0.05）。在初诊和1年诊时,非配对监测组和配对监测组BMI和HbA1c方面比较,差异均无统计学意义（P均>0.05）。 结论配对血糖监测方案有助于糖尿病患者依据血糖结果调整饮食,促进健康饮食行为,并提高其血糖监测依从性。     

The effects of home monitoring by public health nurse on individuals' diabetes control.

Diabetes is an important health problem that changes the lifestyle of individuals. The ability of individuals to control their disease is directly related to their adaptation to the disease and self-care. The purpose of this study was to determine the effect of home monitoring of individuals with diabetes for the purpose of developing their self-care and their adaptation to diabetes. The research used a quasi-experimental (time series) design study. A convenient sample of 34 patients receiving outpatient diabetes care at Hacettepe University Adult Hospital Endocrinology Clinic participated in the study on a voluntary basis. After being seen for the first time in the clinic, they were followed up for a 6-month period in their homes. At the end of the home monitoring period, these patients with diabetes had a statistically significant decrease in HbA(1c) (glycated hemoglobin; p = .000), fasting blood glucose (p = .001), postmeal blood glucose (p = .000), and systolic blood pressure (p = .007) measurements. Diabetes is a quite frequently seen chronic and progressive disease. Nursing monitoring is important to develop an individual's skills in self-care and to support compliance to diabetes. This study supports the finding that the home monitoring of individuals with diabetes by community health nurse improves diabetic control. It is recommended that individuals with diabetes be monitored not only in the hospital but also in their homes for a comprehensive evaluation.     

Evaluating concordance to American Diabetes Association standards of care for type 2 diabetes through group visits in an uninsured or inadequately insured patient population

OBJECTIVE: To evaluate the effectiveness of a managed care approach to health care delivery, group visits, in the management of uninsured or inadequately insured patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 120 patients with uncontrolled type 2 diabetes were randomly assigned to receive their care in group visits or usual care for 6 months. After 6 months, concordance with 10 process-of-care indicators recommended by the American Diabetes Association (ADA) standards of care was evaluated through chart abstraction. The 10 items evaluated were up-to-date HbA(1c) levels and lipid profiles, urine for microalbumin, appropriate use of ACE inhibitor or angiotensin receptor blockers, use of lipid-lowering agents where indicated, daily aspirin use, annual foot examinations, annual referrals for retinal examinations, and immunizations against streptococcal pneumonia and influenza. RESULTS: Patients who received care in group visits showed statistically significant improvement in concordance with these 10 process-of-care indicators (P < 0.001). Of the patients, 76% who received care in group visits had at least 9 of these 10 items up to date, as compared with 23% of control patients; 86% of patients in group visits had at least 8 of the 10 indicators compared with 47% of control patients. CONCLUSIONS: Group visits proved more effective in promoting concordance with ADA standards of care than usual care in the treatment of uninsured or inadequately insured patients with type 2 diabetes.     

Diabetes in urban African-Americans. XV. Identification of barriers to provider adherence to management protocols.

OBJECTIVE: To determine whether health care providers appropriately identify patients with poor glycemic control and to investigate reasons why providers may fail to intensify therapy in these patients. RESEARCH DESIGN AND METHODS: Our management protocol calls for providers to advance diabetes therapy in patients with fasting plasma glucose levels > 7.8 mmol/l or random plasma glucose levels > 10.0 mmol/l. During a 3-month period, providers completed a questionnaire at the end of individual patient visits by asking whether the patient was well controlled and whether therapy was advanced. If therapy was not advanced in patients perceived to have poor control, providers were asked to provide a justification. RESULTS: Providers appropriately identified 88% of well-controlled patients and 94% of patients with poor glycemic control. Out of 1,144 patient visits, control was reported to be good in 508 and poor in 636. In these 636 visits, therapy was advanced in 490 but not in 146 visits. The dominant reasons for failure to intensify therapy were the perception by the provider that control was improving (34%) or the belief that the patient was not compliant with diet or medications (25%). Less common reasons included acute illness, patient refusal, and recurrent hypoglycemia. Based on fasting glucose levels, protocol adherence was 55% before the questionnaire, 64% during the questionnaire (P = 0.006), and 63% afterwards. CONCLUSIONS: Providers in a specialty diabetes clinic appropriately classified patients according to glycemic control and tended to intensify therapy when indicated in most poorly controlled patients. Provider self-survey of behavior and decision making may be an effective strategy to improve adherence to management protocols.     

动态血糖监测图谱在糖尿病健康教育中的应用研究

目的 探讨动态血糖监测图谱在糖尿病患者健康教育中的应用效果。 方法 212例糖尿病患者随机分为对照组与观察组各106例。对照组在住院期间参加糖尿病健康教育集体讲座,观察组在参加健康教育集体讲座的基础上,利用患者本人动态血糖监测图谱结果进行一对一教育。观察2组糖尿病知识理论成绩、自护行为能力评分、糖化血红蛋白值的变化。 结果 观察组理论成绩高于对照组,自护行为能力评分高于对照组,出院3个月糖化血红蛋白值明显低于对照组。 结论 动态血糖监测图谱可对患者的饮食及运动等行为产生持续影响,促进糖尿病患者健康行为的建立。