Medical Clinics Versus Usual Care for Patients With Both Diabetes and Hypertension

Edelman, David; Fredrickson, Sonja K.; Melnyk, S. Dee; Coffman, Cynthia J.; Jeffreys, Amy S.; Datta, Santanu K.; Jackson, George L.; Harris, Amy; Hamilton, Natia S.; Stewart, Helen; Stein, Jeannette; Weinberger, Morris

doi:10.7326/0003-4819-152-11-201006010-00001

Cited by 141 publications

(280 citation statements)

References 33 publications

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“…This lack of integration with primary care may have weakened the intervention; this has been a concern for other telephone management interventions as well. 31 It is also possible that, while the telephone was an important modality for intervention delivery at the time that prior studies were conducted, patients now prefer web-or text- Regarding the BP outcome, we have had extensive experience with this part of the intervention, and we do not think that our content was inadequate to effect BP lowering. In contrast, we had not previously developed a DM intervention.…”

Section: Discussionmentioning

confidence: 99%

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

et al. 2015

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BACKGROUND: Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions. OBJECTIVE: To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases. DESIGN: The study was designed as a patient-level randomized controlled trial. PARTICIPANTS: Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c]≥ 7.5 %) but could have well-controlled HTN. INTERVENTIONS: All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM-and HTN-focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention). MAIN OUTCOMES AND MEASURES: Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point. RESULTS: Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD=1 %) and mean SBP was 142 mmHg (SD=20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention -control), at 24 months, intervention patients had similar A1c [diff=0.1 %, 95 % CI (−0.3, 0.5), p=0.51] and SBP [diff=−0.9 mmH g, 95% CI (−5.4, 3.5), p=0.68] values compared to control patients. Likewise, DBP (diff=0.4 mmHg, p=0.76), weight (diff=0.3 kg, p=0.80), and physical activity levels (diff=153 MET-min/week, p=0.41) were similar between control and intervention patients. Results were also similar at the 6-and 12-month time points. CONCLUSIONS: In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.

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Section: Discussionmentioning

confidence: 99%

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

et al. 2015

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“…74,76,78 Twelve of the 18 studies reported measures of variability. 4,49,61,62,69,72,73,74,76,78,80,82 Most (66 %) of these studies showed no statistically significant differences between groups (N=8) 49,61,69,73,74,78,80,82 ; however, studies had limited power due to small numbers of events. Three of the remaining four studies showed significantly less hypoglycemia in the intervention groups, 4,72,76 while one study showed significantly less hypoglycemia in the usual care group.…”

Section: Safetymentioning

confidence: 99%

“…The strength of the evidence for short-term mortality was graded as moderate, given that results were precise, direct, and had low risk of bias (Table 2). Table 7), 4,21,49,61,62,69,[72][73][74][75][76][77][78][79][80][81][82][83] showing no clear differences between groups in hypoglycemia. The strength of evidence was graded as low, given the inconsistency and imprecision of the results (Table 2).…”

Section: Safetymentioning

confidence: 99%

“…Most studies reported hypoglycemia as total hypoglycemic events [75][76][77] (N=5) or p a r t i c i p a n t s e x p e r i e n c i n g h y p o g l y c e m i a ( N = 8). 61,62,69,73,74,78,80,82 Hypoglycemic outcomes were defined heterogeneously, with some studies based on self report 4,21,62,72,73,77,82 and others on glucose readings. 74,76,78 Twelve of the 18 studies reported measures of variability.…”

Section: Safetymentioning

confidence: 99%

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Effectiveness and Safety of Patient Activation Interventions for Adults with Type 2 Diabetes: Systematic Review, Meta-Analysis, and Meta-regression

et al. 2014

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BACKGROUND: Patient activation interventions (PAIs) engage patients in care by promoting increased knowledge, confidence, and/or skills for disease self-management. However, little is known about the impact of these interventions on a wide range of outcomes for adults with type 2 diabetes (DM2), or which of these interventions, if any, have the greatest impact on glycemic control. METHODS: Electronic databases were searched from inception through November 2011. Of 16,290 citations, two independent reviewers identified 138 randomized trials comparing PAIs to usual care/control groups in adults with DM2 that reported intermediate or longterm outcomes or harms. For meta-analyses of continuous outcomes, we used a random-effects model to derive pooled weighted mean differences (WMD). For allcause mortality, we calculated the pooled odds ratio (OR) using Peto's method. We assessed statistical heterogeneity using the I 2 statistic and conducted meta-regression using a random-effects model when I 2 >50 %. A priori meta-regression primary variables included: intervention strategies, intervention leader, baseline outcome value, quality, and study duration. RESULTS: PAIs modestly reduced intermediate outcomes [A1c: WMD 0.37 %, CI 0.28-0.45 %, I 2 83 %; SBP: WMD 2.2 mmHg, CI 1.0-3.5 mmHg, I 2 72 %; body weight: WMD 2.3 lbs, CI 1.3-3.2 lbs, I 2 64 %; and LDLc: WMD 4.2 mg/dL, CI 1.5-6.9 mg/dL, I 2 64 %]. The evidence was moderate for A1c, low/very low for other intermediate outcomes, low for long-term mortality and very low for complications. Interventions had no effect on hypoglycemia (evidence: low) or short-term mortality (evidence: moderate). Higher baseline A1c, pharmacistled interventions, and longer follow-up were associated with larger A1c improvements. No intervention strategy outperformed any other in adjusted meta-regression. CONCLUSIONS: PAIs modestly improve A1c in adults with DM2 without increasing short-term mortality. These results support integration of these interventions into primary care for adults with uncontrolled glycemia, and provide evidence to insurers who do not yet cover these programs. INTRODUCTIONType 2 diabetes is common and contributes to excess morbidity, mortality, and health care costs, accounting for approximately one in five U.S. health care dollars. 1,2 Behavioral interventions are one important way to improve patient outcomes, 3 yet less is known about a subset of novel behavioral interventions focused on engaging patients in care 4-6 (often termed "patient activation" 7,8 ). Hibbard et al. 7,9 have described patient activation interventions as those that promote motivation, knowledge, and disease self-management skills. 7,9 Despite the growing evidence suggesting improved patient outcomes by engaging patients, 4-6,10 these interventions are often not integrated into practice due to uncertainty about benefit, lack of resources needed for integration, lack of health insurance coverage across insurers, and lack of clarity on the best strategies to incorporate. 11,12 Understanding the imp...

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“…Shared medical appointments (SMA's) are an innovative interdisciplinary model in improving care for chronic diseases including diabetes care [6][7][8][9][10][11] . SMA's are defined as group visits in which several patients meet with one or more provider(s) at the same time [8][9][10][11][12][13][14][15] .…”

Section: Introductionmentioning

confidence: 99%

The utilization of video-conference shared medical appointments in rural diabetes care

Tokuda

Lorenzo

Theriault

et al. 2016

International Journal of Medical Informatics

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Aim: To explore whether Video-Shared Medical Appointments (video-SMA), where group education and medication titration were provided remotely through video-conferencing technology would improve diabetes outcomes in remote rural settings. Methods:We conducted a pilot where a team of a clinical pharmacist and a nurse practitioner from Honolulu VA hospital remotely delivered video-SMA in diabetes to Guam. Patients with diabetes and HbA1c ≥7% were enrolled into the study during 2013-2014. Six groups of 4-6 subjects attended 4 weekly sessions, followed by 2 bi-monthly booster video-SMA sessions for 5 months. Patients with HbA1c ≥7% that had primary care visits during the study period but not referred/recruited for video-SMA were selected as usual-care comparators. We compared changes from baseline in HbA1c, blood-pressure, and lipid levels using mixed-effect modeling between video-SMA and usual care groups. We also analyzed emergency department (ED) visits and hospitalizations. Focus groups were conducted to understand patient's perceptions. Results:Thirty-one patients received video-SMA and charts of 69 subjects were abstracted as usual-care. After 5 months, there was a significant decline in HbA1c in video-SMA vs. usualcare (9.1±1.9 to 8.3±1.8 vs. 8.6±1.4 to 8.7±1.6, P=0.03). No significant change in blood-pressure or lipid levels was found between the groups. Patients in the video-SMA group had significantly lower rates of ED visits (3.2% vs. 17.4%, P=0.01) than usual-care but similar hospitalization rates. Focus groups suggested patient satisfaction with video-SMA and increase in self-efficacy in diabetes self-care. Conclusion:Video-SMA is feasible, well-perceived and has the potential to improve diabetes outcomes in a rural setting.3

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Medical Clinics Versus Usual Care for Patients With Both Diabetes and Hypertension

Abstract: U.S. Department of Veterans Affairs Health Services Research and Development Service.

Cited by 141 publications

References 33 publications

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Effectiveness and Safety of Patient Activation Interventions for Adults with Type 2 Diabetes: Systematic Review, Meta-Analysis, and Meta-regression

The utilization of video-conference shared medical appointments in rural diabetes care

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