Diabetes Management In Primary Care Research Articles

Risk of Dementia Among Patients With Diabetes in a Multidisciplinary, Primary Care Management Program

Although poorly controlled diabetes is associated with a higher incidence of dementia, few studies have examined the association of diabetes management interventions with dementia incidence. To examine the association of receiving a multidisciplinary diabetes management program (the Risk Assessment and Management Program-Diabetes Mellitus [RAMP-DM]) that enables better glycemic control with subsequent risk of dementia incidence and the association of dementia with glycemic control. This territory-wide, retrospective, matched cohort study with more than 8 years of follow-up was conducted using electronic health care records from all the patients who used public health care services in Hong Kong from 2011 to 2019. Eligible participants included all patients with type 2 diabetes (T2D) who were managed in primary care settings. Patients who received RAMP-DM were matched in a 1:1 ratio with patients who received usual care only. Data analysis occurred from April 2023 to July 2023. Diagnosis of T2D, hemoglobin A1C (HbA1C) level, and attendance at a general outpatient clinic or family medicine clinic. Patients received either RAMP-DM or usual care. Incidence of all-cause dementia and subtypes of dementia were compared between the RAMP-DM and usual care participants using a Cox proportional hazard model with other baseline characteristics, biomarkers, and medication history adjusted. HbA1C levels were measured as a secondary outcome. Among the 55 618 matched participants (mean [SD] age, 62.28 [11.90] years; 28 561 female [51.4%]; 27 057 male [48.6%]), including the 27 809 patients in the RAMP-DM group and 27 809 patients in the usual care group, patients had been diagnosed with T2D for a mean (SD) of 5.90 (4.20) years. During a median (IQR) follow-up period of 8.4 (6.8-8.8) years, 1938 patients in the RAMP-DM group (6.97%) and 2728 patients in the usual care group (9.81%) received a diagnosis of dementia. Compared with those receiving usual care, RAMP-DM participants had a lower risk of developing all-cause dementia (adjusted hazard ratio [aHR], 0.72; 95% CI, 0.68-0.77; P < .001), Alzheimer disease (aHR, 0.85; 95% CI, 0.76-0.96; P = .009), vascular dementia (aHR, 0.61; 95% CI, 0.51-0.73; P < .001), and other or unspecified dementia (aHR, 0.71; 95% CI, 0.66-0.77; P < .001). Compared with having a mean HbA1C level during the first 3 years after cohort entry between 6.5% and 7.5%, a higher risk of dementia incidence was detected for patients with a 3-year mean HbA1C level greater than 8.5% (aHR, 1.54; 95% CI, 1.31-1.80]), between 7.5% and 8.5% (aHR, 1.33; 95% CI, 1.19-1.48), between 6% and 6.5% (aHR, 1.17; 95% CI, 1.07-1.29), and 6% or less (aHR, 1.39; 95% CI, 1.24-1.57). In this cohort study of patients with T2D, the findings strengthened evidence of an association of glycemic control with dementia incidence, and revealed that a multidisciplinary primary care diabetes management program was associated with beneficial outcomes for T2D patients against dementia and its major subtypes. A moderate glycemic control target of HbA1C between 6.5% and 7.5% was associated with lower dementia incidence.

Association of treatment satisfaction and physician trust with glycemic control among primary care patients with type 2 diabetes in Egypt.

To evaluate the association of diabetes treatment satisfaction and trust in family physicians with glycemic control among primary care patients with type 2 diabetes mellitus. A cross-sectional study on 319 patients with type 2 diabetes mellitus from five primary healthcare centers in Egypt. Data were collected from February to August 2021 using a structured questionnaire that contained six parts: sociodemographic data, disease profile, the Diabetes Treatment Satisfaction Questionnaire (DTSQ), 8-item Morisky Medication Adherence Scale (MMAS-8), self-reported medication knowledge questionnaire (MKQ), and revised healthcare relationship trust scale (HCR). Multiple linear regression analysis was used to assess predictors of treatment satisfaction, physician trust, and HbA1c level. P values less than 0.05 were considered significant. The mean age was 59.66 years (± 7.87 years) and 55.17% were females. Multiple linear regression analysis for predicting HbA1c showed that HbA1c level was lower in patients with higher treatment satisfaction scores (β = - 0.289, p < 0.001) and higher medication adherence scores (β = - 0.198, p = 0.001). Treatment satisfaction scores were positively predicted by higher physician trust scores (β = 0.301, p < 0.001), increased medication adherence scores (β = 0.160, p = 0.002), and longer duration of diabetes (β = 0.226, p < 0.001). Positive predictors for physician trust included HbA1c level (β = 0.141, p = 0.012), medication knowledge (β = 0.280, p < 0.001), diabetes treatment satisfaction (β = 0.366, p < 0.001) and medication adherence (β = 0.146, p = 0.011). Optimizing diabetes treatment satisfaction and physician trust could have favorable associations with medication adherence and medication knowledge with a possible improvement in glycemic control. Family physicians should incorporate patients reported outcomes alongside traditional clinical measures in evaluating diabetes management in primary care.

1080-P: Missed Opportunities to Address Hypoglycemia Risk in Older Adults with Type 2 Diabetes during Symptom-Driven Primary Care Visits

Older adults with type 2 diabetes (T2D) treated with insulin and/or sulfonylureas (SUs) are at increased risk for hypoglycemia-related adverse events (e.g. falls, decreased quality of life, and death). Because aging is associated with changes in physiology, visual acuity, and dietary habits, diabetes treatment regimens require regular re-assessment. However, despite the importance of ensuring safe diabetes care in older adults, prior research has shown that diabetes is often not addressed during primary care visits due to limited time and competing demands. We tested the hypothesis that diabetes management in primary care occurs less frequently during visits scheduled for acute symptoms/concerns (i.e., “reactive visits”) vs. pre-scheduled annual/physical exam visits intended for health maintenance (i.e., “proactive visits”). We conducted structured chart abstraction for 123 older adults with T2D prescribed insulin and/or SUs to examine the association of visit context (reactive vs proactive) with physician-documented diabetes management, defined as any documentation of diabetes control, blood sugar levels, or diabetes-related medications. Patients were 78.6 ± 3.65 years old, 52.8% were women, pre-visit HbA1c was 7.4% ±0.9%. We found that diabetes documentation in these patients was much less frequent in reactive vs. proactive visits (50.7% vs. 69.8%, p = 0.02). In a logistic model, this association remained significant after controlling for demographic differences (aOR 2.4, 95% CI = 1.1-5.3). In this model, HbA1c ≥8% was also independently associated with diabetes documentation (aOR 3.3 [1.1-10.1]). Treatment with insulin or SUs exposes aging adults to a high risk of hypoglycemia, especially during times of change. Although chart documentation may underestimate actual visit interactions, our results suggest that visits made to discuss acute concerns are a missed opportunity to review and address diabetes care in high-risk patients. Disclosure E.Tang: None. I.Peterson: None. C.Board: None. R.W.Grant: None. Funding Patient-Centered Outcomes Research Institute (CDR-2019C1-16126)

379-P: Don’t Ask, Don’t Tell—How Primary Care Is Failing to Address Fear of Hypoglycemia

Fear of hypoglycemia (FOH) contributes to medication nonadherence and lower quality of life, and may be unrecognized by clinicians. We conducted the first multicenter study examining how primary care providers (PCPs) address FOH. This mixed methods study examined audio-recorded visits between patients using hypoglycemia-causing medications (N=237) and their PCPs (N=50) at 4 geographically diverse Veterans Affairs medical centers from 2017-2020. Two investigators independently coded transcripts to identify discussions related to FOH and analyzed the dialogue using a directed content analysis approach. Results: participants’ mean age was 67 years, 89% were male, and 66% and 42% used insulin and sulfonylureas, respectively. FOH was not assessed by the PCP in any of the 237 visits. FOH was reported by 16 patients (6.8%) unprompted (“I met a lady coming the other day, her sugar dropped and she didn't make it. So that's why I was scared”). Among patients who expressed FOH, 88% reported a recent hypoglycemic event, and half stated that it prevented them from taking their medications (“I’m scared to take my medicine because I don’t want it to go down too low”). In response to FOH, most PCPs gathered hypoglycemia history (n=13) or counseled for prevention (n=11). Some PCP’s responded by moving to a new topic (n=2), or by chastising the patient (n=2) (“You're just using the insulins erratically⋯ It's dangerous, Mr. [name]. We keep reminding you”). Two PCPs provided validation (“It’s very scary probably”); no PCP explored the impact on the patient’s life. In conclusion, FOH is likely under-recognized in primary care as PCPs do not assess for it. Patients reporting FOH often struggle to take their diabetes medications as directed. PCPs respond to FOH by appropriately seeking to prevent recurrent events, but there are missed opportunities to provide support and empathy. Greater awareness, routine assessment, and empathy for at-risk patients who fear hypoglycemia is needed to improve diabetes management in primary care. Disclosure S.J.Pilla: None. N.M.Maruthur: Other Relationship; Johns Hopkins HealthCare Solutions. M.Beach: None. K.Meza: None. J.A.Long: None. H.S.Gordon: None. J.T.Bates: None. D.Washington: None. B.G.Bokhour: None. A.Tuepker: None. S.Saha: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK128572); U.S. Department of Veterans Affairs (IIR 14-007)

E-Capacity: instructional design and pilot test of a Massive Online Open Course for diabetes management in primary care.

e-Capacity: instructional design and pilot test of a Massive Online Open Course for diabetes management in primary care.

Screening for depression as part of annual diabetic review using PHQ-9 scores: a pilot study.

Diabetes mellitus is associated with an increased risk of depression. Appropriate screening and treatment of depression may therefore support diabetes management in primary care. Study aim was to review the efficacy of using a Patient Health Questionnaire - (PHQ-9) tool to screen for depression in patients with type 2 diabetes mellitus (T2DM) in New Zealand.It was a cross-sectional study that included 100 consecutive patients with T2DM from two urban practices in Hamilton, New Zealand. Patients were screened using PHQ-9 scores.Using the PHQ-9, the overall prevalence of depression was 29% including 11 patients under active management/prescribing for depression and 18 undiagnosed patients. By ethnicity, depression affected 41.3%, 33.0%, 25.0% and 13.3% of NZ European, Māori, Pacific and other ethnicities, respectively. PHQ-9 scoring is an easy to administer tool that can be used to screen for unrecognized depression in patients with diabetes as a part of an annual diabetic review.

Com o semblante de médico: experiências de estudantes de medicina durante a simulação clínica em Diabetes tipo 2

This qualitative research aimed to understand the experiences of a fourth-year medical class during two clinical simulation scenarios of type 2 diabetes management in Primary Care. Ten simulated students were interviewed. The results describe the symbolic conception of diabetes and its treatment as anguish, damage, condemnation and an unpleasant sentence that affects the appropriation and performance of the medical role by students. Considering Medical Psychology, we suggest that such subjective factors should be addressed in teaching-learning in addition to commonly cognitive aspects mentioned in the medical education literature in order for students to develop the work profile to cope with diabetes in Primary Care. Clinical simulation facilitates the subjective approach through its group support component to promote reflection, insights and self-awareness.

Effects of Diabetes Quality Assessment on Diabetes Management Behaviors Based on a Nationwide Survey

Improved diabetes management in primary care is essential for reducing the public health burden of diabetes, and various programs are being implemented in Korea for this purpose. Although the Health Insurance Review and Assessment (HIRA) evaluates the quality of type 2 diabetes management in primary care clinics and hospitals, it is unclear whether the implementation of these evaluations is related to the adequate management of complications in diabetic patients. We evaluated the association between the proportion of clinics managing diabetes well and lifestyles and uptake of screening for complications in 24,620 diabetic participants of the 2019 Korean Community Health Survey (KCHS). Multivariate multilevel logistic regression was performed to evaluate the fixed effect of the district-level variable and the heterogeneity among districts. The proportion of clinics with good diabetes management per 10,000 inhabitants was positively related to screening for diabetes complications. Furthermore, this district variable was significantly related to engaging in walking activity (Odds ratio: 1.39, 95% CI: 1.10-1.76) and sufficiently explained the heterogeneity among districts. However, current smoking and weight control were not associated with the proportion of clinics with good diabetes management. The financial incentives to primary care clinics would improve the primary prevention of diabetic complications.

Evaluation of type 2 diabetes care management in nine primary care practices before and after implementation of the Criteria of Good Disease Management of Diabetes established by the Swiss Society of Endocrinology and Diabetology.

Little is known about the quality of diabetes management of patients with type 2 diabetes mellitus (T2DM) in Swiss primary care. Based on the recommendations of the National Council Quality Assurance Programme, an interprofessional working group of the Swiss Society of Endocrinology and Diabetology (SSED) established population-based national criteria for good disease management of T2DM in primary health care (the diabetes score). The objective of this study was to assess whether the implementation of these criteria improve diabetes management in primary care. The diabetes score comprises eight criteria including three biometric measurements, two lifestyle-specific items and screening of three diabetes-associated complications. Practices can evaluate adherence to the criteria based on a point system, with the recommended aim to achieve ≥70/100 points. Group practices and single practices were included in this study and started implementing the SSED criteria in January 2018. The resulting score was compared with data retrospectively obtained for 2017. The primary endpoint was the overall change in Diabetes Score between 2017 and 2018 at each practice, further stratified by practice type. The absolute effect on individual diabetes score criteria was assessed by pooling all patient-level data. Nine practices (six single and three group) participated in the study. In 2017 and 2018, the primary care practices treated 727 and 704 patients with T2DM, respectively, of whom 676 were treated both years. Around half of the patients were cared for in group practices and half in single practices. Between 2017 and 2018 the median (interquartile range) diabetes score improved from 40 (35, 65) to 55 (45, 70; p = 0.078). One practice (single) obtained a score ≥70 in 2017, three practices (all single) achieved this target in 2018. Pooling patient-level data, we observed a significant absolute improvement in the following criteria: number of regular diabetes check ups, body mass index, glycated haemoglobin, blood pressure, low density lipoprotein cholesterol and screenings for diabetes-associated complications (all p <0.05). However, the extent of the improvements were often insufficient to reach the prefixed targets of the diabetes score criteria on the practice level. Overall, the implementation of the SSED criteria in the current setting led to a modest, nonsignificant improvement of the diabetes score. Only three (all single practices) out of the nine practices reached the recommended 70-point target, indicating that further strategies are needed to improve diabetes care in primary care practice. Trial registration: ClinicalTrials.gov (ID NCT04216875).

1241-P: Cross-Sectional Study of the Impact of the COVID-Pandemic on Diabetes Management in Primary Care in Ontario, Canada

Background: This study describes the impact of the pandemic on the management of people with type 2 diabetes (PwT2D) in a primary care network with existing virtual care capabilities in Ontario, Canada. Methods: Using de-identified primary care electronic medical records, PwT2D who had at least one healthcare touchpoint between March 1, 2018 and February 28, 2021 were analyzed by time period (baseline: 2018-19, pre-COVID-19: 2019-20, COVID-19: 2020-21) . The primary outcome measures include the number of people with at least one visit, number of people with vital measurements or lab tests, and the vital or lab results. Results: The three time periods had a similar average age and gender distribution (Table 1) . Compared to the pre-COVID-period, fewer people had any healthcare touchpoint (17% reduction) . In-person visits were reduced while more people had virtual visits. Fewer people had test results recorded during the COVID-vs. two pre-COVID-time periods, however, average results were similar across all three time periods. Conclusion: Our study described the immediate impact of the COVID-pandemic on patterns of primary care for PwT2D. While the total number people getting tests remains below pre-pandemic levels, of those who sought care, the mean A1c, LDL-c and eGFR were comparable across the three time periods. Disclosure A.Y.Cheng: Advisory Panel; Abbott, AstraZeneca, Bayer AG, Boehringer Ingelheim International GmbH, Dexcom, Inc., Eli Lilly and Company, HLS Theraoeutics, Insulet Corporation, Janssen Pharmaceuticals, Inc., Medtronic, Novo Nordisk, Sanofi, Board Member; Type 1 Diabetes Think Tank Network, Other Relationship; Diabetes Canada, Speaker's Bureau; Bausch Health, Canada, Merck &amp; Co., Inc. S.B.Harris: Consultant; Abbott, AstraZeneca, Eli Lilly and Company, Novo Nordisk, Sanofi, Other Relationship; Abbott, AstraZeneca, Bayer Inc., Dexcom, Eli Lilly and Company, HLS Therapeutics, Janssen Pharmaceuticals, Inc., Novo Nordisk, Sanofi, Research Support; Applied Therapeutics Inc., AstraZeneca, Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation (JDRF) , Novo Nordisk, Sanofi, The Lawson Foundation. I.E.Krawchenko: Speaker's Bureau; Janssen Pharmaceuticals, Inc. R.Tytus: Other Relationship; Banty , Boehringer Ingelheim International GmbH, Canadian Health Research Company, Merck &amp; Co., Inc., Novo Nordisk, Pfizer Inc. J.Hahn: Employee; Novo Nordisk Canada Inc. A.R.Liu: Employee; Novo Nordisk A/S, Novo Nordisk Canada Inc. Y.Wang: Other Relationship; Novo Nordisk Canada Inc. S.Golden: Other Relationship; Novo Nordisk Canada Inc. R.Goldenberg: Consultant; IQVIA Inc., Speaker's Bureau; Amgen Canada, AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Janssen Pharmaceuticals, Inc., Merck &amp; Co., Inc., Novo Nordisk Canada Inc., Sanofi.

530-P: Complex Diabetes Management in Primary Care: Confidence and Opportunities for Specialty Support

Access to specialized diabetes care is limited due to shortage of endocrinologists and distance to specialty clinics. In addition, referrals to out-of-network providers frequently results in suboptimal care coordination. Tele-mentoring models such as ECHO (Extension for Community Healthcare Outcomes) extends specialty knowledge to primary care providers. Prior to the implementation of a series of ECHO sessions, we assessed provider confidence in managing type 2 diabetes (T2D) . Methods: Prescribing providers (PP) from three VA Health Care Systems in Florida (North Florida/South Georgia) , Texas (Valley Coastal Bend) and Wisconsin (Milwaukee) were invited to participate. We asked questions about practice patterns, prescription habits, and confidence level treating T2D. Results: A total of 49 PP completed the assessment. Mean age was 42.5 years and 74% were females. They were clinical pharmacists (63%) , physicians (22%) , ARNP (8%) , and the rest were trainees. Clinical experience &amp;lt; 5 year was present in 14.2%, whereas 67% had &amp;gt; years. Half of the providers felt very or extremely confident managing a complicated case (A1c&amp;gt;8% on two oral agents) , whereas only 14% of providers felt either “not at all” or somewhat confident. Most of the providers felt very or extremely confident obtaining a diabetes-focused history (63%) , educating patients about complications (69%) , or changing insulin regimens (61%) . Although most of the providers prescribed a glucose meter very often or always (81%) , only 6% of them prescribed a continuous glucose monitor frequently. When sending a referral, 32% mentioned either lack of local endocrinologists or long waiting time as main barriers. Providers felt that patients prefer to stay with their local VA PCP for diabetes care instead of seeing a specialist (65%) Conclusions: A third of providers perceive significant barriers to access specialized diabetes care. There are opportunities to improve provider confidence and skills managing diabetes. Disclosure C.E.Mendez: Advisory Panel; Monarch Medical Technologies . K.Hazen: None. L.M.Semeah: None. J.A.Leey: None. E.A.Mattox: None. S.Kadiyala: None. M.Xhikola: None. K.Yantsides: None. A.D.Oien: None. I.O'shaughnessy: None. A.E.Hansen: None. J.Lucas: None. Funding Veterans Rural Health Resource Center - 00RH

Interprofessional Collaboration and Diabetes Management in Primary Care: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes.

The global spread of diabetes poses serious threats to public health requiring a patient-centered approach based both on interprofessional collaboration (IPC) given by the cooperation of several different health professionals, and patients’ perspective through the assessment of Patient-Reported Outcomes (PROs). The aim of the present study is to evaluate the impact of interprofessional collaboration interventions, for the management of type 2 diabetes in primary care settings, through PROs. A systematic review and meta-analysis was conducted querying the PubMed, Scopus and Embase databases. Out of the 1961 papers initially retrieved, 19 met the inclusion criteria. Interprofessional collaboration is significantly associated with an increase in both patient’s satisfaction (SMD 0.32 95% CI 0.05–0.59) and in the mental well-being component of the HRQoL (SMD 0.18; 95% CI 0.06–0.30), and there was also promising evidence supporting the association between an interprofessional approach and an increase in self-care and in generic and specific quality-of-life. No statistical differences were found, supporting the positive impact on IPC interventions on the physical component of the HRQoL, depression, emotional distress, and self-efficacy. In conclusion, the effect of IPC impacts positively on the few areas assessed by PROMs. Policymakers should promote the widespread adoption of a collaborative approach as well as to endorse an active engagement of patients across the whole process of care.

Differences in Persistently Elevated Hemoglobin A1c for African American and White Patients and the Role of Provider-Level Variation.

African Americans with type 2 diabetes (T2D) have higher average A1c levels than White patients. However, few studies have examined racial disparities in diabetes management in primary care, particularly provider-level variability. Study goals were to analyze racial differences for patients with any/2 or more elevated A1cs, explore patterns of visits/providers seen in patients with ≥1 elevated A1c, and explore the contributions of provider variability in patient A1c. A retrospective secondary analysis of electronic medical record data from a large urban health system was conducted, involving adult African American or White patients (ages18-65 years) with ≥2 measured A1cs between January 1, 2017-February 1, 2018. Descriptive statistics were calculated for demographic variables; paired t tests evaluated changes in A1c levels across the 2 most recent measurements, and a repeated measures ANOVA evaluated the impact of race on A1c changes. Logistic regression analyses examined the relationship of race with any elevated A1c levels and persistent A1c levels (≥ 2 consecutive A1c measurements ≥8.5). The intraclass correlation coefficient (ICC) estimated clustering of A1c by provider. A total of 1764 patients were included. African Americans were more likely to have any (odds ratio [OR] = 1.48, P < .001) and persistently elevated A1c (OR = 1.75, P = .0003). ICC was .27 for any elevated A1c and .32 for persistently elevated A1c. In primary care patients with T2D, African Americans were more likely than Whites to have any/persistently elevated A1c, with substantial variability attributable to the provider. Further research is needed to better understand patient- and provider-level contributors to A1c disparities.

Challenges in the Management of Diabetes in Primary Care

Diabetes management in primary care is critical to reducing the occurrence and severity of complications through blood sugar management and early detection. A chronic disease management in primary care pilot project, based on the Chronic Care Model (CCM) model that provides patient education on, regular monitoring blood glucose level, medication intake, healthy lifestyle practice, and complications has been developed and applied. Primary care in Korea should provide appropriate education to patients with diabetes and increase the rate of complication testing. In addition, it is of the utmost importance to establish an infrastructure for medical staff to manage patients on a team basis and to establish a patient management system in the community by strengthening primary center (private) and public health care center (public) cooperation activities. Keywords: Care coordinator, Chronic Care Model, Diabetes management in primary center, Private-public cooperation

The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis.

Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.

Evaluating a post-implementation electronic medical record training intervention for diabetes management in primary care

ObjectiveThis study evaluated the potential for electronic medical record (EMR) video tutorials to improve diabetes (type 1 and 2) care processes by primary care physicians (PCP) using OSCAR EMR.DesignA QUAN(qual)...

Current Status and Future Directions for Electronic Point-of-Care Clinical Decision Support to Improve Diabetes Management in Primary Care.

In the past decade there have been major improvements in the design, use, and effectiveness of point-of-care clinical decision support (CDS) systems to improve quality of care for patients with diabetes and related conditions. Advances in data exchange, data security, and human factors research have driven these improvements. Current diabetes CDS systems have high use rates, high clinician/user satisfaction rates, and have measurably improved glucose control, blood pressure control, and cardiovascular risk trajectories in adults with diabetes. As diabetes care increasingly relies on complex biomarker-driven risk prediction methods to optimize care goals and prioritize treatment options based on potential benefit to an individual patient, CDS systems will become indispensable tools to guide clinician and patient decision-making. In this study we describe specific challenges that must be addressed further to improve the design, implementation, and effectiveness of primary care diabetes CDS systems in coming years.

Commentaries on health services research

Commentaries on health services research

Clinical outcomes of an integrated primary-secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial.

The aim of the study was to determine if a Beacon model of integrated care utilising general practitioners (GPs) with special interests could achieve similar clinical outcomes to a hospital-based specialist diabetes outpatient clinic. This pragmatic non-inferiority multisite randomised controlled trial assigned individuals with complex type 2 diabetes to care delivered by a Beacon clinic or to usual care delivered by a hospital outpatient department, in a 3:1 ratio. Owing to the nature of the study, researchers were only blinded during the allocation process. Eligible participants were aged 18 or over, had been referred by their usual GP to the hospital central referral hub with type 2 diabetes and had been triaged to be seen within 30 or 90days. The intervention consisted of diabetes management in primary care by GPs with a special interest who had been upskilled in complex diabetes under the supervision of an endocrinologist. The primary outcome was HbA1c at 12months post-recruitment. The non-inferiority margin was 4.4mmol/mol (0.4%). Both per-protocol and intention-to-treat analyses are reported. Between 27 November 2012 and 14 July 2015, 352 individuals were recruited and 305 comprised the intention-to-treat sample (71 in usual care group and 234 in the Beacon model group). The Beacon model was non-inferior to usual care for both the per-protocol (difference -0.38mmol/mol [95% CI -4.72, 3.96]; -0.03% [95% CI -0.43, 0.36]) and the intention-to-treat (difference -1.28mmol/mol [95% CI -5.96, 3.40]; -0.12% [95% CI -0.55, 0.31]) analyses. Non-inferiority was sustained in a sensitivity analysis at 12months. There were no statistically or clinically significant differences in the secondary outcomes of BP, lipids or quality of life as measured by the 12 item short-form health survey (SF-12v2) and the diabetes-related quality of life (DQoL-Brief) survey. Safety indicators did not differ between groups. Participant satisfaction on the eight-item client satisfaction questionnaire (CSQ-8) was good in both groups, but scores were significantly higher in the Beacon model group than the usual care group (mean [SD] 28.4 [4.9] vs 25.6 [4.9], respectively, p < 0.001). In individuals with type 2 diabetes, a model of integrated care delivered in the community by GPs with a special interest can safely achieve clinical outcomes that are not inferior to those achieved with gold-standard hospital-based specialist outpatient clinics. Individuals receiving care in the community had greater satisfaction. Further studies will determine the cost of delivering this model of care. Australian New Zealand Clinical Trials Registry ACTRN12612000380897 FUNDING: The study was funded by the Australian National Health and Medical Research Council (GNT1001157).

Effectiveness of joint specialist case conferences for building general practice capacity to enhance diabetes care

PurposeType 2 diabetes mellitus has become a major concern of Australian healthcare providers. From rates of barely more than 1 percent in the mid-90s, diabetes is now the leading cause of morbidity in the country. To combat the growing diabetes epidemic, Western Sydney Local Health District created the Western Sydney Diabetes (WSD) initiative. One of the key components of the WSD initiative since 2014 has been joint specialist case conferencing (JSCC). The purpose of this paper is to evaluate the JSCC service including both individual- and practice-based changes.Design/methodology/approachThe authors evaluated the JSCC program by conducting an analysis of patient-level data in addition to a discrete practice-level study. The study aim was to examine both the effect on individual patients and the practice, as well as acceptability of the program for both doctors and their patients. The evaluation included data collection and analysis of primary patient outcomes, as well as a survey of GPs and patients. Patient data on primary outcomes were obtained by accessing and downloading them through GP practice management software by GP practice staff.FindingsThe authors found significant improvements at both the patient levels, with reductions in BMI, HbA1c and blood pressure sustained at three years, and at the practice level with improvements in markers of patient management. The authors also found high acceptability of the program from both patients and GPs.Originality/valueThis paper provides good evidence for the use of a JSCC program to improve diabetes management in primary care through capacity building with GPs.