Family behavior is associated with diet and exercise self-care. Diabetes educators and healthcare providers should consider involving the entire family in the management of older patients with type 2 diabetes. Interventions designed to improve diabetes self-management should address family support specific to diabetes, self-efficacy, and barriers to self-care.

Improving health outcomes relies on patients' full engagement in prevention, decision-making, and self-management activities. Health literacy, or people's ability to obtain, process, communicate, and understand basic health information and services, is essential to those actions. Yet relatively few Americans are proficient in understanding and acting on available health information. We propose a Health Literate Care Model that would weave health literacy strategies into the widely adopted Care Model (formerly known as the Chronic Care Model). Our model calls for first approaching all patients with the assumption that they are at risk of not understanding their health conditions or how to deal with them, and then subsequently confirming and ensuring patients' understanding. For health care organizations adopting our model, health literacy would then become an organizational value infused into all aspects of planning and operations, including self-management support, delivery system design, shared decision-making support, clinical information systems to track and plan patient care, and helping patients access community resources. We also propose a measurement framework to track the impact of the new Health Literate Care Model on patient outcomes and quality of care.

Policy efforts aimed at reducing the number of preventable hospitalizations among the elderly should address the complex health care delivery needs of those Medicare beneficiaries who have special health care needs because they are very old, black, live in core SMSA or rural counties, have poor overall health status, and have physical limitations. Efforts to reduce the number of Medicare beneficiaries who experience a preventable hospitalization may be cost-effective as these beneficiaries may account for up to 17.4% of Medicare's reimbursement for inpatient, outpatient, and physician services in our data set.

These findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

PURPOSE Participatory decision making (PDM) is associated with improved diabetes control. We examine a causal model linking PDM to improved clinical outcomes that included patient activation and medication adherence. METHODSThis observational study was conducted in 5 family physician offi ces. Diabetic patients were recruited by mail and by completing a study interest card at the conclusion of their offi ce visit. Two survey questionnaires, administered 12 months apart, elicited patients' ratings of their physician's PDM style at baseline and their level of activation and medication adherence both at baseline and at follow-up. Measures of glycated hemoglobin (hemoglobin A 1c ), systolic blood pressure, and low-density lipoprotein (LDL) cholesterol were abstracted from the medical record starting 12 months before the baseline survey to 12 months after the follow-up survey. A path analysis using a structural equation model was used to test hypotheses. RESULTSWe mailed questionnaires to 236 participants; 166 (70%) returned the baseline questionnaire, and 141 (80%) returned the follow-up questionnaire. Hemoglobin A 1c levels, systolic blood pressure, and LDL cholesterol values all declined signifi cantly, and patient activation and medication adherence improved. PDM at baseline was associated with patient activation at follow-up. Patient activation at follow-up was associated with medication adherence at follow-up, and medication adherence at follow-up was associated with change in hemoglobin A 1c levels and LDL cholesterol values but not with systolic blood pressure.CONCLUSIONS Participatory decision making during primary care encounters by patients with type 2 diabetes resulted in improvements in hemoglobin A 1c levels and LDL cholesterol values by improving patient activation, which in turn improved medication adherence.

PURPOSE This study aimed to examine the contribution of competing demands to changes in hypoglycemic medications and to return appointment intervals for patients with type 2 diabetes and an elevated glycosylated hemoglobin (A 1c ) level. METHODSWe observed 211 primary care encounters by adult patients with type 2 diabetes in 20 primary care clinics and documented changes in hypoglycemic medications. Competing demands were assessed from length of encounter, number of concerns patients raised, and number of topics brought up by the clinician. Days to the next scheduled appointment were obtained at patient checkout. Recent A 1c values and dates were determined from the chart. RESULTSAmong patients with an A 1c level greater than 7%, each additional patient concern was associated with a 49% (95% confi dence interval, 35%-60%) reduction in the likelihood of a change in medication, independent of length of the encounter and most recent level of A 1c . Among patients with an A 1c level greater than 7% and no change in medication, for every additional minute of encounter length, the time to the next scheduled appointment decreased by 2.8 days (P = .001). Similarly, for each additional 1% increase in A 1c level, the time to the next scheduled appointment decreased by 8.6 days (P = .001). CONCLUSIONSThe concept of clinical inertia is limited and does not fully characterize the complexity of primary care encounters. Competing demands is a principle for constructing models of primary care encounters that are more congruent with reality and should be considered in the design of interventions to improve chronic disease outcomes in primary care settings. 2007;5:196-201. DOI: 10.1370/afm.679. Ann Fam Med INTRODUCTIONA lthough tight glucose control can prevent or delay the onset of complications in patients with type 2 diabetes mellitus, 1-3 optimal control is frequently not achieved. [4][5][6] Recently, poor glucose control has been attributed to so-called clinical inertia on the part of physicians, defi ned as "recognition of the problem, but failure to act." [7][8][9][10][11][12] Some have even proposed methods for a measure of clinical inertia as a quality of care indicator. 13 The phenomenon of clinical inertia has been diffi cult to study because of the paucity of data on the content of the patient-physician encounter. All published studies of clinical inertia to date have used administrative or medical record data.An alternative explanation for failure to intensify therapy despite poor glucose control is the presence of competing demands.14-18 Encounters are bounded by a time constraint within which multiple diagnoses, problems, and patient concerns compete with each other for a place on the agenda. Physicians and patients prioritize demands and only deal with the most pressing or symptomatic problem.14 Problems perceived to be less urgent, for example, intensifying medication therapy for poorly controlled glycosylated hemoglobin (A 1c 1. As the length of the encounter decreases, the likelihood of a change in hy...

Continuity of care with a primary care provider is associated with better glucose control among patients with type 2 diabetes. This relationship appears to be mediated by changes in patient behavior regarding diet.

Effective delivery of primary care to patients with one or more chronic illnesses may be important in decreasing the level of hassles they experience as they interact with the health care delivery system.