Diabetes care.

Providing good quality diabetes care is complex but achievable. Many aspects of the care do not require high tech medicine but, rather, good organisation. Diabetes is a costly disease, consuming 1500 pounds per diabetic patient per year versus 500 pounds on average for a non-diabetic member of the population in health service costs. Investment now in good quality diabetes care is sound: patients will benefit from a better quality of life associated with a reduced incidence of the complications of diabetes and the direct costs to the health service in treating these complications and the indirect costs to employers will be reduced. Physical and clinical assessments--measurements of blood glucose and glycosylated haemoglobin concentrations, weight, and blood pressure and assessment of eyes, kidneys, feet, and heart--are clearly important, but quality must include consideration of people and their reactions to life and diabetes--a lifelong entanglement--for which much more support should be provided.     

Diabetes care program addresses specific needs

Experienced nurse peer educators are keys to program's success. Hospital-sponsored community program may be a model for others to follow. Program also benefits hospitals by reducing length of stay for diabetic patients.     

Diabetes care among veteran women with disability

OBJECTIVE: The primary objective of this study was to analyze predictors of diabetes care consistent with performance standards among women Veterans Health Administration (VHA) clinic users with disability enrollment status. METHODS: This is a retrospective cohort study using VHA and Medicare files of VHA clinic users with diabetes. Diabetes care measures consisted of annual testing for hemoglobin A(1c) (HbA(1c)), low-density lipoprotein cholesterol (LDL-C), and poor HbA(1c) (>9%) and LDL-C (> or =130 mg/dL) control in fiscal year 2000. Chi-square tests and logistic regressions were used to assess subgroup differences in diabetes care. Independent variables included demographic characteristics and physical and psychiatric comorbidities. POPULATION: Study population was based on veteran women <65 years of age who used VHA clinics; we identified 2,344 women as having coexisting disability and diabetes and 2,766 women with diabetes and without disability. FINDINGS: Among veteran women with diabetes and disability, 65% received > or =1 HbA(1c) test, and 54% received a LDL-C test; 25% and 30% had poor HbA(1c) and LDL-C control, respectively. In logistic regressions, none of the independent variables had significant effects on poor HbA(1c) or LDL-C control, except that African Americans were more likely to have poor HbA(1c) control than whites. Significant age effects were noted in rates of HbA(1c) and LDL testing. Comparison of diabetes care measures between women with and without disability indicated that those with disability were more likely to receive HbA(1c) and LDL-C tests; no significant differences in HbA(1c) and LDL-C control were noted. CONCLUSIONS: Disability status of women veterans was not a barrier to diabetes care consistent with performance standards. Our findings suggest that to improve diabetes care, subgroup-specific interventions, rather than a global approach, are warranted.     

Diabetes and depression care among medicaid beneficiaries

This study evaluates the relationship between diabetes mellitus and depression care among non-elderly Medicaid beneficiaries, using claims data from the 1995 State Medicaid Research Files for Alabama, Georgia, New Jersey, and Wisconsin. Presence of comorbid diabetes was found to be significantly associated with a higher rate of depression diagnosis. Among those who were diagnosed as depressed, treatment of comorbid diabetes was associated with a higher rate of antidepressant treatment than among depression-diagnosed patients who did not also have diabetes. However, among patients with diabetes and depression, a quarter received only tricyclic antidepressants. Controlling for other characteristics, African Americans diagnosed with depression were less likely to receive antidepressant treatment and, if they did receive such treatment, more likely to receive the older tricyclic drugs. These findings raise concern for glycemic control among patients with diabetes and depression treated with tricyclic antidepressants in a low-income Medicaid population. Among depressed Medicaid beneficiaries with diabetes, there are racial differences with regard to quality of mental health care in the presence of diabetes.     

Diabetes care in the San Francisco County Jail

Chronic disease management is becoming increasingly important in correctional settings, especially diabetes. We conducted a retrospective chart review of diabetic inmates in San Francisco County Jail and examined the sociodemographic characteristics, markers of disease status, and compliance with jail-specific care guidelines within this setting. We found high rates of compliance with immediate-term care guidelines (e.g., finger-stick glucose and blood pressure checks at intake) but less success in providing the more complex care required for chronic diseases. Inmates' age, race, and gender did not affect likelihood of meeting guidelines.     

Diabetes preventive care in Oregon's Medicaid population.

The purpose of this study was to estimate the prevalence of diabetes in Oregon's adult Medicaid population and to compare the level of diabetes-related preventive care with the state's general population. Responses to telephone interviews conducted in 1999 among 2,770 randomly selected adult Medicaid beneficiaries and 7,229 Oregon residents were compared. Diabetes prevalence among adult Medicaid recipients (11.1% [95% Cl, 9.9% to 12.2%]) was more than twice that in the general population (4.7% [95% Cl, 4.2% to 5.3%]). During the year prior to the interview, adults with diabetes in the Medicaid and general populations reported performing the following preventive care, respectively: > or = 2 diabetes care visits (80%, 77%); foot examination (74%, 74%); dilated eye examination (73%, 68%); influenza vaccine (65%, 61%); self-monitored blood glucose daily (63%, 61%); pneumococcal vaccine (51%, 47%); regular aspirin use (48%, 53%); and awareness of Hemoglobin A1c (34%, 39%). Although the reported prevalence of diabetes in Oregon's Medicaid population is high, the prevalence of diabetes preventive care activities was similar to the state's general population. Nonetheless, specific services in both populations could be improved.     

Diabetes care management participation in a primary care setting and subsequent hospitalization risk.

Scant evidence exists that examines the impact of participation in primary care diabetes management programs and their educational components on the risk of subsequent significant patient morbidity. This study examined the association between participation in a diabetes management program in a primary care setting and the risk of subsequent hospitalization. Ten thousand nine hundred eighty patients with diabetes mellitus receiving some type of treatment in a large primary care clinic network in Houston, TX were examined for incidence of hospitalization in the year 2002. Information from the year preceding the hospitalization was obtained on several demographic, clinical, and diabetes care management participation related variables. Multivariate logistic regressions were used to examine the relationship between primary care diabetes management participation as well as individual educational components and the likelihood of subsequent-year hospitalization. Patients participating in some type of primary care diabetes management were 16% less likely to have an incidence of hospitalization (p = 0.05). When individual educational components of the diabetes care management program were examined, diabetes education sessions were more beneficial than certified diabetes educator visits in reducing the incidence of hospitalization. Patients with controlled blood glucose levels and a diabetes education session seemed to have the most significant reduction in hospitalization risk (odds ratio [OR] = 0.62; 95% CI: 0.40, 0.95). There seem to be beneficial effects associated with participation in primary care diabetes management programs in terms of reduced hospitalization risk. Attendance at diabetes educational sessions in primary care settings coupled with maintenance of blood glucose control seem to be associated with greatest risk reduction.     

Diabetes disease management in Medicaid managed care: a program evaluation.

The objective of this study was to evaluate the outcomes of a diabetes disease management initiative among TennCare's Medicaid Population. A quasi-experimental group design was conducted using a control group and a diabetes disease management intervention group. Primary outcomes measures were rates for three key recommended tests (ie, microalbuminuria, lipids, and hemoglobin A1c). Secondary performance measures --patient satisfaction and program evaluation issues -- also were assessed. The study was performed among TennCare beneficiaries with diabetes mellitus. It utilized a quasi-experimental nonequivalent control group design, with 993 intervention participants in Knoxville and 1167 control group members in Chattanooga. Variables analyzed included testing rates for hemoglobin A1c, lipids, microalbuminuria, and demographics. A logistic regression model using baseline covariates was constructed to analyze the differences between the intervention and the control groups. Intracluster correlations were accounted for by generalized estimating equations. Statistical process control detected process changes in testing rates over time. There were meaningful changes in the rate of ordering recommended tests. The odds of an individual in the intervention group having at least one microalbuminuria test were 196% more (confidence interval [CI] = 1.50, 5.82; p = 0.002); the odds of having at least one lipid profile were 43% more (CI = 1.01, 2.02; p = 0.042); and the odds of having two or more hemoglobin A1c tests were 39% more (CI = 0.87, 2.23; p = 0.165) than the odds of an individual in the control group. The analysis also showed a high rate of satisfaction among patients in the intervention group. The program was successful in meeting its stated goals of providing effective disease management for TennCare patients with diabetes.     

Diabetes care in a rural primary health care district where patient education is given high priority. Metabolic evaluation

The present population-based study comprises 84% of all known diabetics cared for at a rural primary health care centre. Patient education has been given high priority as an integral part of the treatment provided by a specially trained nurse and dietician under the supervision of the general practitioners. Most of the patients were under good metabolic control, as reflected by HbA1 (diet-treated, n = 119, 7.3 +/- 1.3%; oral agent-treated, n = 127, 7.8% +/- 1.3%; insulin-treated, n = 110, 8.0 +/- 1.3%; reference range 5.3-7.3%). Obvious reasons for any high HbA1 values were found.     

Diabetes and lipid screening among patients in primary care: A cohort study

Background  

Obesity is associated with increased cardiovascular diseases and diabetes mellitus. Guidelines call for intensified glucose and lipid screening among overweight and obese patients. Data on compliance with these guidelines are scarce. The purpose of this study was to assess rates of diabetes and lipid screening in primary care according to demographic variables and weight status.     

糖尿病护理管理中采用全程健康模式价值及对自我效能影响

目的探讨在糖尿病护理管理中行全程健康模式的应用价值,以及对患者自我效能的影响。方法将322例糖尿病患者随机分为对照组和观察组,各161例,对照组行常规护理管理,观察组在此基础上行全程健康模式。随访6个月后比较2组自我效能、知识知晓率、护理满意度。结果护理后观察组的自我效能总分为(111.24±11.94)分,对照组为(85.12±11.24)分,观察组明显高于对照组,差异显著(P﹤0.05);观察组的知识知晓率为95.0%,明显较对照组的66.5%高,差异显著(P﹤0.05);观察组的护理满意度为93.2%,明显较对照组的73.3%高,差异显著(P﹤0.05)。结论对糖尿病患者采用全程健康护理模式,可有效提高患者的自我效能评分、知识知晓率及护理满意度,从而控制病情发展。     

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.