Microalbumin Screening Research Articles

Improving care practices of the patient with type 2 diabetes in community health centers.

Diabetes ranks seventh in morbidity and mortality in the United States. In addition, more than 25 million Americans living with diabetes depend on community health centers (CHCs) for primary care. Preimplementation data in a group of CHCs indicated poor adherence to standards of care practices as recommended by the American Diabetes Association (ADA) with quarterly A1c (33.1%), annual serum laboratory tests (66.6%), and annual urine microalbumin (26.5%). Using a pre- and postimplementation comparison method, a NP-led practice improvement project was conducted in a group of CHCs, which sought to (1) identify adherence to ADA care standards; (2) determine whether an intervention could affect adherence to ADA standards; and (3) compare pre- and postimplementation occurrences of hemoglobin A1c greater than 7.1% and greater than 9%. Intervention composed of an educational component, standing orders to facilitate care practice changes, and electronic health record utilization changes. Postimplementation data reveal statistically significant improvements in quarterly hemoglobin A1c (93.6%), annual serum laboratory tests (96.5%), and annual urine microalbumin screening (85.5%). Improvements in translation to care for standardized guidelines facilitate improvements in health outcomes for patients. This project demonstrated improvements that can decrease the morbidity and mortality experienced by persons living with diabetes and being seen within a CHC. In addition, this project demonstrated that advanced practice nurses have the training and occupy a unique position within health care to spearhead initiatives for translation of evidence into care practices.

2408-PUB: Benchmarking Care Outcomes for Youth with Diabetes after Transition to Adult Care in Australia

In 2001 a model of care for transition of youth with diabetes (YWD) was implemented at Westmead Hospital and published in 2007. In 2017, Australian National Diabetes audit (ANDA) conducted a month survey of all people with diabetes attending participating centers. The Australian Diabetes Data Network (ADDN) is a newly established national database. Aim: To determine if benefits are conferred by a youth specific transition care model as compared with other Australian adult health care settings for YWD age 16-25. Methods: An audit of all T1D Westmead clinic attendees aged 16-25 in 2017 including age, duration diabetes, HbA1c, urine microalbumin/creatinine ratio in the last 12 months, BP, most recent retinal review and results compared with the ANDA outcomes for youth attending adult health care settings for management of diabetes. Subjects within 1 year diagnosis and pregnancy excluded. Results: Key: HbA1c median (25th-75th centile), [n] missing * p<0.05. HbA1c did not differ across all adult centers. In subgroup analysis only MDI treated were lower in the ANDA centers. A significantly greater proportion had urine microalbumin screening and BP screening, in the Westmead cohort. Conclusion: Similar levels of diabetes control were achieved regardless of center indicating importance of follow-up in this age group although control was suboptimal. Complications screening was more effective with a dedicated transition. Disclosure J. Holmes-Walker: None. P. Rueter: None. K. Farrell: None.

Quality of care for type 2 diabetes mellitus in Tripoli Medical Center: a retrospective study of 628 patients

Introduction . Diabetes mellitus (DM) is a major public health problem. Evidence has shown that aggressive control of hyperglycemia and associated risk factors reduces the risk of both macrovascular and micro­vascular complications. The aim of this study was to determine the proportion of diabetes patients reaching the targets recommended by The American Diabetes Association (ADA) standards for diabetes care. Methods and materials. This is a retrospective study, conducted at the diabetes outpatient clinics at TMC. For 628 patients with diabetes with at least two clinic visits in the 24 months before August 2010, we as­sessed measurement and control of HbA1c, blood pressure, and lipid, the data were collected in a spe­cially designed data sheet, and analyzed using SPSS program. Results. 628 patients were studied. The mean age was 49.6 ± 11.8 years; average duration of diabetes was 6.5 ± 5.0 years. The mean last HbA1c was 8.2 ± 2.4%. 75.1% attained a systolic blood pressure of < 140 and 75.7% attained a diastolic blood pressure of < 90 mm Hg. Only 30.8% had LDL cholesterol of < 100 mg/dL and 49.0% had a triglyceride level of < 150 mg/dL. The rate of annual foot examination, retinal examination screening, and urine microalbumin screening were low. Conclusions. This study demonstrates a low rate of diabetes care targets achievement among patients with type 2 diabetes treated at TMC. (Clin Diabetol 2017; 6, 6: 204–210)

Diabetes Quality of Care Before and After Implementation of a Resident Clinic Practice Partnership System.

Deficiencies in resident diabetes care quality may relate to continuity clinic design. This retrospective analysis compared diabetes care processes and outcomes within a traditional resident continuity clinic structure (2005) and after the implementation of a practice partnership system (PPS; 2009). Under PPS, patients were more likely to receive annual foot examinations (odds ratio [OR] = 11.6; 95% confidence interval [CI] = 7.2, 18.5), microalbumin screening (OR = 2.4; 95% CI = 1.6, 3.4), and aspirin use counseling (OR = 3.8; 95% CI = 2.5, 6.0) and were less likely to receive eye examinations (OR = 0.54; 95% CI = 0.36, 0.82). Hemoglobin A1c and lipid testing were similar between periods, and there was no difference in achievement of diabetes and blood pressure goals. Patients were less likely to achieve cholesterol goals under PPS (OR = 0.62; 95% CI = 0.39, 0.98). Resident practice partnerships may improve processes of diabetes care but may not affect intermediate outcomes.

Prevalência da microalbuminúria em doentes hipertensos e/ou diabéticos tipo 2 nos Cuidados de Saúde Primários em Portugal: Estudo RACE (micRoAlbumin sCreening survEy)

Introduction and ObjectivesTo determine the prevalence of microalbuminuria (MAU) in outpatients with hypertension and/or type 2 diabetes mellitus (DM) and in normotensive, non‐diabetic outpatients (control group); and, as secondary objectives, to examine the differences in the distribution of MAU in the four subgroups and the association of different clinical and epidemiological variables with MAU. MethodsRACE (micRoAlbumin sCreening survEy) was a multicenter, descriptive observational cross‐sectional study, which enrolled outpatients followed in primary care in Portugal. Patients with potential reasons for a false‐positive MAU test were excluded. The main outcome measures were the prevalence of MAU as assessed by Micral® test strips and blood pressure. Demographic variables, presence of comorbidities, use of cardiovascular and antidiabetic drugs and biochemical variables were also analyzed. ResultsA total of 9198 patients (3769 with hypertension, 3100 with both DM and hypertension, 423 with DM and without hypertension, and 1906 controls), 54.7% women, were included in the primary analysis. Overall prevalence of MAU was 58% in patients with DM and hypertension, 51% in patients with DM, 43% in patients with hypertension, and 12% in controls (chi‐square: p<0.001 for all subgroups). In multivariate analysis, predictors for MAU were the presence of DM or hypertension, HbA1C, male gender, age, systolic blood pressure and total cholesterol. ConclusionsMAU is extremely common in outpatients with DM and/or hypertension followed in primary care, especially in those with both hypertension and DM and high cardiovascular risk. MAU screening would help identify individuals at risk and increase awareness of kidney disease and target organ damage.

Prevalence of microalbuminuria in hypertensive patients with or without type 2 diabetes in a Portuguese primary care setting: The RACE (micRoAlbumin sCreening survEy) study

Introduction and ObjectivesTo determine the prevalence of microalbuminuria (MAU) in outpatients with hypertension and/or type 2 diabetes mellitus (DM) and in normotensive, non-diabetic outpatients (control group); and, as secondary objectives, to examine the differences in the distribution of MAU in the four subgroups and the association of different clinical and epidemiological variables with MAU. MethodsRACE (micRoAlbumin sCreening survEy) was a multicenter, descriptive observational cross-sectional study, which enrolled outpatients followed in primary care in Portugal. Patients with potential reasons for a false-positive MAU test were excluded. The main outcome measures were the prevalence of MAU as assessed by Micral® test strips and blood pressure. Demographic variables, presence of comorbidities, use of cardiovascular and antidiabetic drugs and biochemical variables were also analyzed. ResultsA total of 9198 patients (3769 with hypertension, 3100 with both DM and hypertension, 423 with DM and without hypertension, and 1906 controls), 54.7% women, were included in the primary analysis. Overall prevalence of MAU was 58% in patients with DM and hypertension, 51% in patients with DM, 43% in patients with hypertension, and 12% in controls (chi-square: p<0.001 for all subgroups). In multivariate analysis, predictors for MAU were the presence of DM or hypertension, HbA1C, male gender, age, systolic blood pressure and total cholesterol. ConclusionsMAU is extremely common in outpatients with DM and/or hypertension followed in primary care, especially in those with both hypertension and DM and high cardiovascular risk. MAU screening would help identify individuals at risk and increase awareness of kidney disease and target organ damage.

A Review of Advances in Collaborative Pharmacy Practice to Improve Adherence to Standards of Care in Diabetes Management

The prevalence of diabetes in the United States is increasing and so is the need to provide diabetes care. Given the time commitment and complexity of diabetes management, an interdisciplinary approach is recommended. Pharmacists are integral members of the diabetes care team because of their accessibility and expertise in medication management. Pharmacists are receiving specialized training and becoming more involved in direct patient care through collaborative practice opportunities such as medication therapy management and collaborative drug therapy management. These collaborative practice models increase patient access to care and allow pharmacists to optimize drug therapy and provide important education to promote diabetes self-management. Studies show pharmacists practicing in a variety of outpatient environments can reduce HbA1c, LDL and BP as well as improve adherence to recommended American Diabetes Association guidelines (yearly monofilament exams, dilated eye exams, microalbumin screening, etc). Pharmacists working as part of the health care team can ensure optimal diabetes management.

Diabetes care quality is highly correlated with patient panel characteristics.

Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs). Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined. Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators. Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.

The epidemic of pediatric chronic kidney disease: the danger of skepticism

The epidemic of pediatric chronic kidney disease: the danger of skepticism

Investment Cost for Microalbumin Screening Compared to Hemoglobin A1C Screening: A Situation From a Rural Province in a Developing Country

Laboratory investigation for following up diabetes mellitus is recommended. Hemoglobin A1C and microalbumin are the two most widely used screening tests. An important concern in developing countries at present is the cost of a screening program. A basic study on the funds for hemoglobin A1C and microalbumin screening in primary hospitals in a rural province in the developing country of Thailand was done. It was found that the fund for microalbumin in this setting is about one-fourth that for hemoglobin A1C. Due to the inequality in funding allocation, there is a need for increased awareness of the importance of microalbumin screening for patients with diabetes mellitus.

Quality of Care for Patients with type 2 Diabetes in Lagos University Teaching Hospital

Background/Objective: Results from clinical trials over the past decade have established a base for specific screening and prophylactic recommendations in patients with type 2 diabetes aimed at achieving optimal metabolic control and risk reduction for the development of chronic complications. We aimed to assess implementation of guidelines of diabetes care based on internationally accepted recommendations of the American Diabetes Association, in patients receiving treatment at the Diabetes clinic of the Lagos University Teaching Hospital. Methods: A cross sectional prospective study involving 114 patients from the Diabetes clinic of the Lagos University Teaching Hospital was carried out. Pre-tested questionnaires were administered. Aspects of plasma glucose, glycated haemoglobin testing, self monitoring of blood or urine glucose, and risk reduction using blood pressure measurements, foot examination, retinal examination, urine microalbumin screening, lipid assay, anti-platelet and ACE inhibitor therapy. The period the questionnaire referred to was the last 1 year of patient care. Results: A total of 63 males, 51 females were seen with type 2 diabetes with a mean age of 56.58+11.2 years. Mean duration of diabetes was 10.8±6.5years, mean BMI was 26.67+5.7kg/m2. Mean fasting plasma glucose was 162+20.4mg/dl. Only 14% of the patients had glycated haemoglobin measurement in the period under review with a mean HbA1c of 10.5+2.0%. All patients had regular blood pressure measurements during clinic visits, (average of 2-3 months) with mean blood pressure of 136.8+19.4/86.3+14.9 mmHg. 71% had foot examination during clinic visits, 48% had dilated fundoscopy, 92% had regular dipstix urinalysis during clinic visits, 50% practiced self monitoring of urine or blood glucose, 61% had regular lipid profiles, 49% were on anti-platelet aspirin therapy and 37.7% were on ACE inhibitors. Conclusion: Certain aspects of the recommendations of standards of medical care are below average. Indices of metabolic control show that the patients seen have poor glycaemic control and sub-optimal blood pressure control. Some aspects of care (glycated haemoglobin, self monitoring) possibly reflect adverse socioeconomic conditions while some possibly reflect inadequate information on the part of the attending residents or physicians. NQJHM Vol. 16 (1) 2005: pp. 6-9

Development and clinical outcomes of pharmacist-managed diabetes care clinics

The development and outcomes of two pharmacist-managed diabetes care clinics (DCCs) are described. Retrospective data analysis was performed to determine the outcomes for patients with type 2 diabetes mellitus who were treated in two pharmacist-managed DCCs. Primary outcome measures included changes in glycosylated hemoglobin (HbA(1c)), fasting plasma glucose, body mass index, low-density-lipoprotein (LDL) cholesterol, high-density-lipoprotein cholesterol, triglycerides, and blood pressure and documented annual retinal and micro-albumin screening. Secondary outcome measures included the use of aspirin and kidney-sparing agents and annual screening for thyroid-stimulating hormone. Data from 113 patients in the DCCs were analyzed. After one year, the mean reduction in HbA(1c) levels was 1.3%, with a mean HbA(1c) of 7.8%. HbA(1c) goals were based on the institution's HbA(1c) normal range of 4.1-6.5%. Compared with baseline, over one third of patients met the HbA(1c) and blood pressure goals of <7.5% and <130/80 mm Hg, respectively. Mean LDL cholesterol concentration decreased from 110 to 94 mg/dL. The mean concentration of triglycerides decreased from 243 to 178 mg/dL. Mean systolic blood pressure decreased from 136 to 132 mm Hg. Whereas the national average for uncontrolled diabetes (HbA(1c) > 9.5%) was 36.9%, only 3.5% of patients at the pharmacist-managed DCCs had uncontrolled diabetes. Attainment rates of LDL cholesterol goals and annual retinal and microalbumin screenings were significantly higher in clinic patients compared with national averages. Three-year postclinic inception data revealed similar favorable outcomes, most notably an average HbA(1c) of 7.6% and 55% of patients meeting their target HbA(1c) goal of <7.5%. Compared with national averages, DCCs managed by clinical pharmacists achieved higher screening rates and attained treatment goals more often.

Pharmacist Impact on Clinical Outcomes in a Diabetes Disease Management Program via Collaborative Practice

Clinical outcomes resulting from pharmaceutical care have been incompletely addressed in the diabetes population. We conducted a retrospective study evaluating clinical outcomes in a diabetes disease management program in which clinical pharmacists possessed collaborative practice agreements. To evaluate changes in clinical outcomes for patients enrolled in a pharmacist-coordinated diabetes management program. Medical records of 157 patients enrolled in the diabetes management program between June 2003 and April 2004 were retrospectively reviewed. Data collection included baseline and follow-up values for hemoglobin A(1C) (A1C) and lipids as well as frequency of adherence to preventive care, including annual foot and eye examinations and daily aspirin therapy. For patients with both baseline and follow-up data, the mean A1C reduction was 1.6% (n = 109; p < 0.001). For patients with an initial A1C of > or =8.5%, the mean reduction was 2.7% (n = 57; p < 0.001). The percentage of patients with A1C < or =7% increased from 19% at baseline to 50% at follow-up (p < 0.001). The mean low-density lipoprotein (LDL) reduction observed was 16 mg/dL (n = 73; NS) and the percentage of patients with LDL values < or =100 mg/dL increased from 30% at baseline to 56% at follow-up (p < 0.001). The frequency of microalbumin screening increased by 27% (p < 0.001), and the number of patients with annual eye and foot examinations increased by 27% (p < 0.05) and 15% (p < 0.05), respectively. The percentage of patients who had a positive microalbumin test and were taking a renal protective agent rose 19% from baseline to follow-up (NS). The percentage of patients taking daily aspirin increased from 42% at baseline to 80% at follow-up (p < 0.01). The pharmacist-coordinated diabetes management program was effective in improving clinical markers for enrolled patients. Significant improvements were observed in A1C and LDL values as well as the frequency of adherence to preventive care.