Diabetes Care Services Research Articles

The effectiveness of an emotion-focused educational programme in reducing diabetes distress in adults with Type 2 diabetes mellitus (VEMOFIT): a cluster randomized controlled trial.

To evaluate the effectiveness of a brief, value-based emotion-focused educational programme (VEMOFIT) in Malay adults with Type 2 diabetes mellitus compared with a programme of active listening to participants' emotional experiences, social support and their opinion on the health clinic diabetes care services (attention control). Malay adults with severe diabetes distress [Diabetes Distress Scale (DDS-17) mean score ≥ 3] were included. VEMOFIT consisted of four biweekly group sessions, a booster session after 3 months and a follow-up 6 months post intervention. The attention control programme consisted of three sessions over the same period. Outcomes included diabetes distress, depressive symptoms, self-efficacy and disease control. Required total sample size was 165. Participants (n = 124) were randomized to either VEMOFIT (n = 53) or the attention control programme (n = 71). Participants had a mean (sd) age of 55.7 (9.7) years, median diabetes duration of 7.0 (8.0) years and mean HbA1c level of 82 mmol/mol (9.7%). The mean DDS-17 level decreased significantly in both the VEMOFIT and the attention control programmes (3.4 to 2.9 vs. 3.1 to 2.7, respectively). The adjusted between-group DDS-17 difference was not significant [-0.01, 95% confidence interval (CI) -0.38, 0.35]. The proportion of individuals with severe diabetes distress decreased in both groups, from 89% to 47% vs. 69% to 39% (odds ratio 0.88; 95% CI 0.26, 2.90). Other outcomes did not differ between groups. Both interventions decreased diabetes distress significantly. The theory-based VEMOFIT programme was not superior to the attention control programme. The latter approach is a simpler way to decrease severe diabetes distress (Trial registration: NCT02730078; NMRR-15-1144-24803).

Improving quality care for diabetes in the community: What do Cypriot patients want?

To measure patient preferences for their diabetic care in community setting. Discrete-choice survey. Community setting (primary physician and hospital sites) in Cyprus. Diabetic patients attending community sites. Patient preferences, to estimate which components of quality healthcare service people value, their relative importance but also the potential shift to shared decision-making (SDM). Older respondents with experience of the private sector already received SDM (managing their care and choosing their treatments; detailed and accurate information, continuity of care; compassion for their personal situation) from their primary care physician with waiting time shorter than 1 h. They valued their 'current' option and they did not want to change it with other services. Younger people from the public sector valued a change in policy and wanted to move from their 'current' to alternative diabetic care services where the waiting times were shorter, they could not only manage their care but also choose their treatments (together with receiving information, continuity of care and compassionate care). Individuals agreed with receiving multidisciplinary care from a team of healthcare providers but they mostly preferred being supported by their primary care physician. The pooled sample valued their 'current' option but they also supported policy changes that would implement SDM service for everybody. Diabetic patients value SDM and are willing to support a shift of practice to receive it not only in the private but also in the public sector. The forthcoming National Health Insurance Service would aim to address such developments as anticipated both in the European Troika's recommendations and the relevant laws.

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

The role of joint working between primary and secondary care in supporting people with type 1 diabetes

Comparison of Diabetic Foot Care with Other Diabetic Preventive Care Services.

Diabetes is a major chronic disease with high morbidity and mortality. Diabetic preventive care services are essential in the management and outcome of the disease. More than other preventive diabetic care services, preventive care of diabetic retinopathy has been emphasized and recommended by practitioners and insurance companies. We investigated the status of preventive care in the diabetic population. Information was collected from 420 outpatients aged 30 to 80 years. The patients were divided into two groups: those with well-controlled blood sugar levels (hemoglobin A1c [HbA1c] level ≤7%) and those with uncontrolled blood sugar levels (HbA1c level >7%). Data analysis indicated that for both groups, 93% of the participants were seen for diabetic eye care at least once and 78% were getting an annual eye examination regularly. In the controlled and uncontrolled blood sugar groups, 26% and 32% of patients, respectively, had ever seen a nephrologist and 38% and 49%, respectively, had ever seen a cardiologist. In the controlled and uncontrolled blood sugar groups, 32% and 38% of patients, respectively, had visited a podiatric physician. For statistical analysis and comparison of results between the two groups, we applied the χ2 test and calculated 95% confidence intervals. There were some significant differences regarding the complications of diabetes mellitus and preventive care. There is a need for greater engagement by podiatric physicians and health-care providers to promote regular visits for the diabetic population to podiatric medical clinics.

Diabetes care in Qatar: a survey of pharmacists' activities, attitudes and knowledge.

Background Diabetes mellitus is recognized as a major public health issue and is one of the top ten causes of death in Qatar. Objective To describe the activities, and attitudes of Qatar pharmacists toward diabetes, to measure their diabetes knowledge and to assess their perceived barriers for diabetes care. Setting Community and ambulatory pharmacies in Qatar. Method Study objectives were addressed in a cross sectional survey of community and ambulatory pharmacists in Qatar. A phone call explaining the study was made to all community and ambulatory pharmacists in Qatar. Consenting pharmacists anonymously completed the survey either online or as paper. Main outcome measure Diabetes related activities, knowledge, attitudes and perceived barriers. Results Over 7months, 126 surveys were collected (28% response rate). The majority of pharmacists always or often counselled patients on the appropriate time to take each medication and on medication side effects (90%, n=100/111 and 73%, n=81/111 respectively). Yet around 50% always or often provided education on the importance of screening for nephropathy (n=59/112) and retinopathy (n=58/109). In addition, 41% always or often provided education about the importance of immunization (n=45/111) and 45% always or often provided therapy recommendations to physicians (n=49/111). Using Diabetes Attitude Scale-3, most respondents had positive attitudes toward the need for special training, psychosocial impact of diabetes, and patient autonomy. Around 25% (n=32/126) scored less than 6 out of 10 on the diabetes related knowledge test. The top three barriers for providing diabetes services were lack of time (53%, n=67/126) shortage of personnel (42%, n=53/126) and lack of private counseling area (42%, n=53/126). Conclusion Qatar pharmacists mainly provide basic services for diabetic patients. They have an average diabetes related knowledge. Yet overall, they have positive attitudes toward diabetes, which is a vital component of any successful diabetes care service.

Formation of a type 1 diabetes young adult patient and public involvement panel to develop a health behaviour change intervention: the D1 Now study

Plain English summaryMany young adults with type 1 diabetes (T1D) find it hard to control their blood glucose levels. With lots of things going on in their lives, their diabetes is often not the most important thing to them. That means they do not always take care of their T1D, for example by going to clinic appointments. Young adults with T1D do not usually get the chance to make suggestions on how to improve diabetes services. Being involved could help young adults to shape the diabetes care services that support them.Since 2014 a diabetes research team based in Galway has been looking at ways to improve how diabetes services are delivered to young adults. Eight young adults (aged 18–25 years) with T1D called the Young Adult Panel (YAP) are members of this team and have helped design the “D1 Now” intervention which aims to improve diabetes services.The YAP came up with questions to ask other young adults with T1D, their families and friends and healthcare providers about their experiences of healthcare services and how these could be improved. The YAP also shared messages from the research at national conferences and on local radio. They helped with writing sections of a grant application to take this research work forward.Our experience has shown the importance of involving young adults with T1D in helping to design research focusing on ways to improve their diabetes service that will help them and other young adults to live with diabetes in the future.Background Research indicates that young adults (18–25 year olds) with type 1 diabetes (T1D) often disengage from health services and their general diabetes management. Involving young adults with T1D in co-designing research to develop a behaviour change intervention to improve engagement with health services could potentially improve overall self management and health. A local youth mental health organisation called Jigsaw, Galway developed a very successful model for involving users in service design and development. Based on this model, the aim was to form a Young Adult Panel (YAP) of 18–25 year olds with T1D and involve them in all aspects of a study to develop an intervention to improve health and wellbeing for young adults with T1D called D1 Now.Methods Recruitment of young adults was achieved through a multimedia campaign. A consultation event was organised, followed by interviews with interested young adults. A panel of 8 members was selected. Following initial training for YAP members in committee skills and an introduction to different research methods and terms, YAP members participated in different stages of the research process. They were represented on the research study steering group and attended research meetings. They developed research materials, reviewed and interpreted research findings and helped develop the online platform to enhance engagement between young adults and their diabetes healthcare providers. They contributed to an international consensus conference on health services delivery for young adults with T1D and wrote specific sections of a further grant application to test out the new intervention.Results As a direct result of the YAP, a meaningful dialogue has opened up between healthcare providers and young adults within the D1 Now research team. Their involvement has led to a better understanding of what needs to be achieved in order to improve health service delivery. They have been active members in co-designing a health behaviour change intervention to improve engagement between young adults with T1D and healthcare providers which will be evaluated in future research.Conclusion Through the formation of the YAP, we have demonstrated that involving young adults with T1D in healthcare research is feasible and productive.

Diabetes management in a foreign land: A case study on Chinese Australians.

The aim of this study was to understand the experience of Chinese migrants living with type 2 diabetes in Australia and explore their culturally specific diabetes management needs, habits and expectations in the Australian context to help shape an Australian Chinese diabetes service. A case study approach was employed across two Australian cities (Melbourne and Sydney), using participant-observations and qualitative interviews. Purposive sampling was used to find diabetes education sessions for observation and facilitators for interviews before snowball technique was used to identify relevant clinicians. Thematic analysis with pattern matching was used for data analysis. A total of 18 participant-observations and 12 interviews were conducted. Chinese migrants appeared to experience multiple barriers in accessing the Australian diabetes care service further complicated by the mismatch between the expectations of Chinese patients and the services available. Chinese patients were observed to be collectivistic-orientated relying on friends for diabetes management. While health professionals appeared to be perceived as a source of reputable health information, they often did not provide ongoing support. When professional support was limited, Chinese patients adopted alternative strategies to address their diabetes, which often involved seeking help and information from peers. Some of this information was non-reputable, potentially resulting in detrimental health outcomes. In conclusion, redesigning diabetes care services in line with the principles of collectivism may more appropriately match the Chinese migrants' expectations and needs, and better support them in their diabetes journey.

What role could community pharmacists in Malaysia play in diabetes self-management education and support? The views of individuals with type 2 diabetes.

This study explored the experiences and views of individuals with type 2 diabetes mellitus (T2D) on their diabetes self-management and potential roles for community pharmacists in diabetes self-management education and support (DSME/S) in Malaysia. A qualitative study, using semi-structured, face-to-face interviews, was conducted with patients with T2D attending a primary care health clinic in Kuala Lumpur, Malaysia. The interviews were audio-recorded, transcribed verbatim and analysed inductively. Fourteen participants with T2D were interviewed. Data were coded into five main themes: experience and perception of diabetes self-management, constraints of the current healthcare system, perception of the community pharmacist and community pharmacies, perceived roles for community pharmacists in diabetes care, and challenges in utilising community pharmacies to provide DSME/S. There were misconceptions about diabetes management that may be attributed to a lack of knowledge. Although participants described potential roles for community pharmacists in education, medication review and continuity of care, these roles were mostly non-clinically oriented. Participants were not confident about community pharmacists making recommendations and changes to the prescribed treatment regimens. While participants recognised the advantages of convenience of a community pharmacy-based diabetes care service, they raised concerns over the retail nature and the community pharmacy environment for providing such services. This study highlighted the need to improve the care provision for people with T2D. Participants with T2D identified potential, but limited roles for community pharmacists in diabetes care. Participants expressed concerns that need to be addressed if effective diabetes care is to be provided from community pharmacies in Malaysia.

Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations

AimTo estimate potential savings for Australia’s health care system through the implementation of an innovative Beacon model of care for patients with complex diabetes. MethodsA prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. We extracted patient hospitalisation data from the Queensland Hospital Admitted Patient Data Collection and used Australian Refined Diagnosis Related Groups to assign costs to potentially preventable hospitalisations for diabetes. Results327 patients with complex diabetes referred by their general practitioner for specialist outpatient care were included in the analysis. The integrated model of care had potential for national cost savings of $132.5 million per year. ConclusionsThe differences in hospitalisations attributable to better integrated primary/secondary care can yield large cost savings. Models such as the Beacon are highly relevant to current national health care reform initiatives to improve the continuity and efficiency of care for those with complex chronic disease in primary care.

Regional disparities in the prevalence of diabetes and diabetic retinopathy in Hungary in people aged 50 years and older

Diabetes mellitus (DM) is one of the main causes of blindness among persons aged 50 years and older. The purpose of our survey was to estimate the prevalence of DM and diabetic retinopathy (DR), as well as to assess the coverage of diabetic eye care services in different regions of Hungary. In 105 clusters, 3675 people aged 50 years and older were included in the survey. The standardized rapid assessment of avoidable blindness (RAAB) with the diabetic retinopathy module (DRM) was used to examine the participants. Thereafter, differences between West-, Middle- and East-Hungary were analysed. Prevalence of DM was higher in East-Hungary (20.9%), than in West- (19.5%) and in Middle-Hungary (19.5%). Prevalence od DR was higher in West-Hungary (24.1%), than in Middle- (17.8%) and in East-Hungary (19.6%). Proportion of participants who never had a fundus examination for DR was the lowest in Middle-Hungary (19.1%). Primary care should be strenghten mainly in country settlements or telemedical eye screening program should be started to decrease the prevalence of diabetic eye complications. Orv. Hetil., 2017, 158(10), 362-367.

Diabetic foot care services avert amputations, save costs

Diabetic foot care services avert amputations, save costs

Measuring socioeconomic inequalities in eye care services among patients with diabetes in Alberta, Canada, 1995-2009.

Diabetic retinopathy (DR) is a leading cause of blindness in Canada. Despite established comprehensive guidelines for routine DR screening, the rate of provision of diabetic eye care services by ophthalmologists in Alberta decreased in past years. The aim of this study was to examine socioeconomic status (SES)-related inequalities in the use of eye care services for patients with diabetes in Alberta, Canada. We used data from the Alberta Diabetes Surveillance System (ADSS), including visits to ophthalmologists over a 15-year period (1995-2009). Socioeconomic inequalities in the use of eye care services were assessed using the Relative Concentration Index (RCI). We used three different SES indicators: median household income and the Canadian material and social deprivation indices (MDI and SDI). Socioeconomic inequalities in use of eye care services exist in patients with diabetes, although the magnitudes of the inequalities were small and steadily decreased over time; income- and MDI-related RCI indicated that individuals with greater income or less material deprivation were more likely to use eye care services. However, for SDI-related RCI, socially deprived individuals were more likely to use eye care services (RCI: 1995: -0.066; 2002: -0.036; 2009: -0.028). Our findings suggest a need for attention to the potential impact of provincial policy on inequalities in eye care services among patients with diabetes, particularly as it relates to geographical differences across regional health zones.

Balancing Primary Diabetes Care Quality and Services.

The editorialist discusses the implications of Cheung and colleagues' study with regard to the relationship between delivery of primary care services and quality.

Enablers and barriers in providing telediabetes services for Indigenous communities: A systematic review

A systematic review of studies which reported on telediabetes services within Indigenous communities was undertaken in June 2016. The aim of this study was to identify enablers and barriers associated with the delivery of telehealth services for diabetes care amongst Indigenous people. A total of 14 articles met the study inclusion criteria, reporting work in Canada, Australia, India, and the US. Key enablers included the use of cultural and spiritual elements, acknowledgement of local beliefs and traditions, and appropriate community engagement. The involvement of Indigenous health workers was also very important because of their role in communication in local language, helping clinicians understand the community, and the transportation of patients. The main barriers associated with telediabetes services were the potentially high fail-to-attend rates, lack of technical skills associated with the operation of telehealth equipment, and the lack of availability of local staff. Knowledge of the enablers and barriers associated with the delivery of healthcare services to Indigenous communities is important when planning a telediabetes service.

Evaluating the impact of an enhanced primary care diabetes service on diabetes outcomes: A before–after study

Diabetes is an ambulatory care-sensitive condition and a high quality primary care or risk factor control can lead to a decrease in the risk of non-elective hospitalisations while ensuring continuity of care with usual primary care teams. Aims and methodsIn this before and after study, eight primary care practices providing a newer enhanced diabetes model of care in Leicester UK, were compared with matched neighbouring practices with comparable demographic features providing a more expensive integrated specialist—community care diabetes service. The primary outcome at twelve months was to demonstrate equivalence in non-elective bed days. The enhanced practices had primary care physicians and nurses with an interest in diabetes who attended monthly diabetes education meetings and provided care plans and audits. The control practices provided an integrated primary-specialist care service. ResultsThe difference between the mean change in the non-elective bed days from baseline and at follow up in core and enhanced practices was not statistically significant (mean=2.20 per 100 patients, 95% CI=−0.92 to 5.31 per 100 patients, p=0.14). The analogous change for first outpatients’ attendance were 0.23 per 100 patients (95% CI=−0.47 to 0.52 per 100 patients p=0.92) and for diabetes related complications admissions was 0.30 per 100 patients (95% CI=−0.85 to 1.45 per 100 patients p=0.55). ConclusionA model of enhanced primary care based diabetes care appears unlikely to increase hospitalisations, outpatients’ attendance or admissions for diabetes related complications.

Diabetes diagnosis and care in sub-Saharan Africa: pooled analysis of individual data from 12 countries

Despite widespread recognition that the burden of diabetes is rapidly growing in many countries in sub-Saharan Africa, nationally representative estimates of unmet need for diabetes diagnosis and care are in short supply for the region. We use national population-based survey data to quantify diabetes prevalence and met and unmet need for diabetes diagnosis and care in 12 countries in sub-Saharan Africa. We further estimate demographic and economic gradients of met need for diabetes diagnosis and care. We did a pooled analysis of individual-level data from nationally representative population-based surveys that met the following inclusion criteria: the data were collected during 2005-15; the data were made available at the individual level; a biomarker for diabetes was available in the dataset; and the dataset included information on use of core health services for diabetes diagnosis and care. We first quantified the population in need of diabetes diagnosis and care by estimating the prevalence of diabetes across the surveys; we also quantified the prevalence of overweight and obesity, as a major risk factor for diabetes and an indicator of need for diabetes screening. Second, we determined the level of met need for diabetes diagnosis, preventive counselling, and treatment in both the diabetic and the overweight and obese population. Finally, we did survey fixed-effects regressions to establish the demographic and economic gradients of met need for diabetes diagnosis, counselling, and treatment. We pooled data from 12 nationally representative population-based surveys in sub-Saharan Africa, representing 38 311 individuals with a biomarker measurement for diabetes. Across the surveys, the median prevalence of diabetes was 5% (range 2-14) and the median prevalence of overweight or obesity was 27% (range 16-68). We estimated seven measures of met need for diabetes-related care across the 12 surveys: (1) percentage of the overweight or obese population who received a blood glucose measurement (median 22% [IQR 11-37]); and percentage of the diabetic population who reported that they (2) had ever received a blood glucose measurement (median 36% [IQR 27-63]); (3) had ever been told that they had diabetes (median 27% [IQR 22-51]); (4) had ever been counselled to lose weight (median 15% [IQR 13-23]); (5) had ever been counselled to exercise (median 15% [IQR 11-30]); (6) were using oral diabetes drugs (median 25% [IQR 18-42]); and (7) were using insulin (median 11% [IQR 6-13]). Compared with those aged 15-39 years, the adjusted odds of met need for diabetes diagnosis (measures 1-3) were 2·22 to 3·53 (40-54 years) and 3·82 to 5·01 (≥55 years) times higher. The adjusted odds of met need for diabetes diagnosis also increased consistently with educational attainment and were between 3·07 and 4·56 higher for the group with 8 years or more of education than for the group with less than 1 year of education. Finally, need for diabetes care was significantly more likely to be met (measures 4-7) in the oldest age and highest educational groups. Diabetes has already reached high levels of prevalence in several countries in sub-Saharan Africa. Large proportions of need for diabetes diagnosis and care in the region remain unmet, but the patterns of unmet need vary widely across the countries in our sample. Novel health policies and programmes are urgently needed to increase awareness of diabetes and to expand coverage of preventive counselling, diagnosis, and linkage to diabetes care. Because the probability of met need for diabetes diagnosis and care consistently increases with age and educational attainment, policy makers should pay particular attention to improved access to diabetes services for young adults and people with low educational attainment. None.

Quality of diabetes care and health insurance coverage: a retrospective study in an outpatient academic public hospital in Switzerland.

BackgroundSocioeconomic disadvantage is associated with an increased risk of adverse diabetes outcomes. In Switzerland, a country with theoretical universal healthcare coverage, people without health insurance face barriers in accessing to and in receiving standard quality care. The Geneva University Hospitals (HUG) have implemented policies aiming at reducing these gaps. We compared quality of diabetes care and ambulatory healthcare services utilization among insured and uninsured diabetic patients.MethodsThis retrospective study linked health and administrative data of type 2 diabetic outpatients with at least one HbA1c test performed in 2012–2013 at HUG. Quality of care evaluation relied on processes (annual serum HbA1c, cholesterol and microalbuminuria tesing) and outcomes (HbA1c) assessment. Healthcare utilization was assessed by the number of ambulatory clinical and laboratory visits. Results were stratified by disease course (newly diagnosed versus prevalent diabetes).ResultsOf the 198 patients included, 80 (40.4 %) were uninsured. Both groups underwent annual testing of HbA1c, cholesterol, kidney function and microalbuminuria at comparably high rates and numbers of ambulatory visits did not significantly differ. After adjustments for age and sex, there were no significant differences in serum HbA1c between groups both in those with prevalent or with newly diagnosed diabetes. Initial medical intervention entailed comparable glycaemic improvement after 6 months in incident diabetes among insured and uninsured patients.ConclusionsThis study did not find any difference in quality of diabetes care between insured and uninsured patients in a public hospital enforcing health-equity policies for access to and for delivery of standard diabetes care. It highlights the frontline role of public hospitals in contributing to care delivery equity even in countries with theoretical universal healthcare coverage.

Proposal for a pharmacogenetics certificate program for pharmacists.

The delivery of pharmacogenetic (PGx) testing has expanded outside of the traditional clinical setting to include community pharmacies. While pharmacists have been involved as a liaison between the clinical testing laboratory and ordering clinician, assisting with interpretation or application of results [1–3], the delivery of clinical testing by a community pharmacist marks another step in the expansion of roles and pharmacy services. Many community pharmacies currently offer tuberculosis testing, blood pressure monitoring, and now some have begun to offer PGx testing. Despite their interest in PGx testing, pharmacists have recognized their limited training and lack of knowledge and skills regarding PGx [4–7]. For several years, professional pharmacy organizations have called for enhanced training and curricula in PGx to prepare pharmacists to use and apply PGx testing [8–13]. Some state pharmacy boards require certification or specialized training to perform certain services, but do not yet require it for PGx testing. In this article, we propose the development of a certification program that pharmacists would be required to complete before offering PGx testing. Pharmacist certification in PGx could ensure the appropriate and safe use of PGx testing and optimize the lifetime benefits to patients. In the USA, training requirements to provide specific pharmacy services are determined and approved by state pharmacy boards. For example, provision of immunization services requires completion of the pharmacy-based immunization delivery certificate training program, which provides pharmacists the knowledge to administer and implement immunization services [14]. For other services, additional training is recommended; completion of the Medication Therapy Management (MTM) Certificate Training Program is recommended for pharmacists wishing to provide MTM services. This training program provides skills-based training on how to interview a patient, identifying and prioritizing medicationrelated programs, developing interventions and documenting activities. States may opt to develop their own training programs or approve completion of training programs offered by national pharmacy groups or private vendors to meet the state requirements. For example, New Mexico pharmacists interested in offering tuberculosis testing must complete a training program offered by the state health department [15]. The American Pharmacist Association (APhA), one of the oldest pharmacy associations, has developed certificate or training programs to ensure pharmacists are qualified to perform certain services for immunization delivery, diabetes care, MTM and cardiovascular disease risk management [16]. A recent search (14 October 2015) of the three types of continuing education programs (knowledge, application, practice) approved by the US Accreditation Council for Pharmacy Education (ACPE [17]) Proposal for a pharmacogenetics certificate program for pharmacists

VA and Medicare Utilization Among Dually Enrolled Veterans with Type 2 Diabetes: A Latent Class Analysis.

Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems. We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes. This was a retrospective cohort. 316,775 community-dwelling Veterans age ≥ 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008-2009. Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression. We identified four distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ≥ 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06-1.15) and 4 (OR 1.11, CI 1.04-1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10-4.51). Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation.

Exploring culturally competent primary care diabetes services: a single-city survey.

AimsTo determine the cultural competence of diabetes services delivered to minority ethnic groups in a multicultural UK city with a diabetes prevalence of 4.3%.MethodsA semi‐structured survey comprising 35 questions was carried out across all 66 general practices in Coventry between November 2011 and January 2012. Data were analysed using descriptive statistics. The cultural competence of diabetes services reported in the survey was assessed using a culturally competent assessment tool (CCAT).ResultsThirty‐four general practices (52%) responded and six important findings emerged across those practices. (1) Ninety‐four per cent of general practices reported the ethnicity of their populations. (2) One in three people with diabetes was from a minority ethnic group. (3) Nine (26.5%) practices reported a diabetes prevalence of between 55% and 96% in minority ethnic groups. (4) The cultural competences of diabetes services were assessed using CCAT; 56% of practices were found to be highly culturally competent and 26% were found to be moderately culturally competent. (5) Ten practices (29%) reported higher proportionate attendance at diabetes annual checks in the majority white British population compared with minority ethnic groups. (6) Cultural diversity in relation to language and strong cultural traditions around food were most commonly reported as barriers to culturally competent service delivery.ConclusionsSeven of the eight cultural barriers identified in the global evidence were present in the city. Use of the CCAT to assess existing service provision and the good baseline recording of ethnicity provide a sound basis for commissioning culturally competent interventions in the future.