The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs

Mangione, Carol M.; Gerzoff, Robert B.; Williamson, David F.; Steers, W. Neil; Kerr, Eve A.; Brown, Arleen F.; Waitzfelder, Beth E.; Marrero, David G.; Dudley, R. Adams; Kim, Catherine; Herman, William H.; Thompson, Theodore; Safford, Monika M.; Selby, Joe V.

doi:10.7326/0003-4819-145-2-200607180-00008

Cited by 124 publications

(93 citation statements)

References 28 publications

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“…Factors related to processes of care, • Resources to support providers' prevention interventions (print or other materials, skilled support staff, cost-efficient intervention formats, office systems, community partnerships) (29). Limited resources for dietary and physical activity counseling.…”

Section: Constructs Explored Findingsmentioning

confidence: 99%

Opportunities and Challenges for Diabetes Prevention at Two Community Health Centers

Rosal

Benjamin²,

Pekow³

et al. 2008

Diabetes Care

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OBJECTIVE -Translating evidence-based diabetes prevention interventions to disadvantaged groups is a public health priority that poses unique challenges. Community health centers (CHCs) provide unequaled opportunities to prevent diabetes among poor and minority highrisk groups. This formative study sought to assess structural, processes-of-care (health care quality domains), and patient factors that need to be considered for diabetes prevention at CHCs. RESEARCH DESIGN AND METHODS -A multimethod approach was implemented to assess system-, provider-, and patient-level factors at two large CHCs serving diverse urban communities.RESULTS -Medical chart audits (n ϭ 303) showed limited documentation of risks. Provider surveys (n ϭ 74) evidenced knowledge gaps regarding factors associated with increased diabetes risk, efficacy of pharmacological interventions, and low perceived efficacy in promoting patient behavior change. Patient focus groups (two groups) with at-risk Hispanics and African Americans suggested mixed knowledge regarding whether diabetes can be prevented, some knowledge gaps regarding factors related to risk, and multiple challenges for lifestyle change.CONCLUSIONS -Multiple and multilevel challenges to translating diabetes prevention interventions for the benefit of at-risk populations who seek care at CHCs were observed. Diabetes Care 31:247-254, 2008T ranslating evidence-based diabetes prevention interventions (1-3) to disadvantaged groups is a challenging public health priority. This study sought to identify patient-, provider-, and system-level opportunities and challenges to delivering diabetes prevention services in community health centers (CHCs). This manuscript adds to current literature on structural, processes-of-care (health care quality domains) (4), and patient factors (5) that need to be considered in the design and implementation of diabetes prevention efforts for the high-risk populations who seek health care at CHCs. RESEARCH DESIGN ANDMETHODS -An ecological framework (6), which recognizes the multiple levels of influence on patients' outcomes within health care settings, including factors associated with the health care system, providers and patients, guided this study. Within this framework, we assessed quality-of-care domains from Donabedian's StructureProcess-Outcome model (4) at the system level (system structure, including health care resources) and at the provider level (processes related to technical expertise and interpersonal relationships with patients). At the patient level, social cognitive theory (5) constructs (knowledge, attitudes, behaviors, and environmental influences) were assessed. Institutional review board approval was obtained before study implementation. SettingTwo large CHCs that were affiliated with a tertiary referral academic medical center in Massachusetts and served urban African Americans (40%) and Hispanics (40%) participated in this study. Both CHCs used a resident-faculty practice model, with each patient being assigned a primary care physician (80% ...

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Section: Constructs Explored Findingsmentioning

confidence: 99%

Opportunities and Challenges for Diabetes Prevention at Two Community Health Centers

Rosal

Benjamin²,

Pekow³

et al. 2008

Diabetes Care

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“…M a n y d i a b e t e s intervention studies are limited by inadequate sample size, nonrandomized patients and clinics, lack of control subjects, or limited scope of implementation within a single medical group or health system (11,13,14). Although some trials of quality improvement strategies have demonstrated small improvements in the process of care delivery, demonstrating improvement in control of A1C, LDL, and systolic blood pressure (SBP) has been more challenging (15)(16)(17)(18). The paucity of effective interventions improving diabetes care in primary care settings led us to design a "practical clinical trial" to test whether implementation of an organizational intervention could improve both diabetes care processes and clinical outcomes in primary care (19).…”

mentioning

confidence: 99%

Improving Diabetes Care in Practice

et al. 2008

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OBJECTIVE -The purpose of this study was to determine whether implementation of a multicomponent organizational intervention can produce significant change in diabetes care and outcomes in community primary care practices.RESEARCH DESIGN AND METHODS -This was a group-randomized, controlled clinical trial evaluating the practical effectiveness of a multicomponent intervention (TRANSLATE) in 24 practices. The intervention included implementation of an electronic diabetes registry, visit reminders, and patient-specific physician alerts. A site coordinator facilitated previsit planning and a monthly review of performance with a local physician champion. The principle outcomes were the percentage of patients achieving target values for the composite of systolic blood pressure (SBP) Ͻ130 mmHg, LDL cholesterol Ͻ100 mg/dl, and A1C Ͻ7.0% at baseline and 12 months. Six process measures were also followed.RESULTS -Over 24 months, 69,965 visits from 8,405 adult patients with type 2 diabetes were recorded from 238 health care providers in 24 practices from 17 health systems. Diabetes process measures increased significantly more in intervention than in control practices, giving net increases as follows: foot examinations 35.0% (P Ͻ 0.0.001); annual eye examinations 25.9% (P Ͻ 0.001); renal testing 28.5% (P Ͻ 0.001); A1C testing 8.1%(P Ͻ 0.001); blood pressure monitoring 3.5% (P ϭ 0.05); and LDL testing 8.6% (P Ͻ 0.001). Mean A1C adjusted for age, sex, and comorbidity decreased significantly in intervention practices (P Ͻ 0.02). At 12 months, intervention practices had significantly greater improvement in achieving recommended clinical values for SBP, A1C, and LDL than control clinics (P ϭ 0.002).CONCLUSIONS -Introduction of a multicomponent organizational intervention in the primary care setting significantly increases the percentage of type 2 diabetic patients achieving recommended clinical outcomes.

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“…(11). The primary objective of the TRIAD Study is to determine how the structural and organizational characteristics of health systems and health care provider groups influence processes and outcomes of diabetes care (12). Six translational research centers collaborate with 10 health plans and 68 provider groups, which serve ϳ180,000 patients with diabetes.…”

mentioning

confidence: 99%

Sex Disparities in Control and Treatment of Modifiable Cardiovascular Disease Risk Factors Among Patients With Diabetes

et al. 2008

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OBJECTIVE -Cardiovascular disease (CVD) mortality has decreased in men but not in women with diabetes. We investigated whether sex differences in control and treatment of CVD risk factors might underlie this disparity.RESEARCH DESIGN AND METHODS -We performed cross-sectional analyses from a cohort of patients with diabetes sampled from 10 U.S. managed care health plans. Study end points included not being in control for CVD risk factors (Ն140 mmHg for systolic blood pressure [SBP], Ն3.35 mmol/l for LDL cholesterol, and Ն8.0% for A1C) and the intensity of medication management (number of medication classes) for patients not in control. Logistic regression models with random intercepts were used to adjust probabilities of control and management for demographics, clinical characteristics, and clustering within health plans.RESULTS -There were 1,315 women and 1,575 men with a history of CVD and 3,415 women and 2,516 men without a history of CVD. Among patients with CVD, adjusted estimated probabilities for not being in control and risk differences varied significantly between men and women for SBP (men 41.2%, women 46.6%; risk difference Ϫ5.4% [95% CI Ϫ9.5 to Ϫ1.3]) and LDL cholesterol (men 22.4%, women 28.3%; risk difference Ϫ5.9% [Ϫ9.9 to Ϫ1.8]). There were no significant sex differences in intensity of medication management for patients not in control. In patients without CVD there were no significant differences in control or intensity of medication management.CONCLUSIONS -In diabetic patients with CVD, poorer control of SBP and LDL cholesterol for women may contribute to the sex disparity in CVD mortality trends. Diabetes Care 31:69-74, 2008

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The Association between Quality of Care and the Intensity of Diabetes Disease Management Programs

Cited by 124 publications

References 28 publications

Opportunities and Challenges for Diabetes Prevention at Two Community Health Centers

Opportunities and Challenges for Diabetes Prevention at Two Community Health Centers

Improving Diabetes Care in Practice

Sex Disparities in Control and Treatment of Modifiable Cardiovascular Disease Risk Factors Among Patients With Diabetes

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